THE ECHO FOUNDATION
presents “One by One by One ...... ”
Paul Farmer & Partners In Health
Student Dialogue March 3, 2009
Hosted at South Mecklenburg High School 8900 Park Road Charlotte, North Carolina
Inspired by Paul Farmer’s relentless determination to deliver healthcare to the poorest among the poor, The Echo Foundation devotes this year’s study to the power of personal commitment. “One by One by One…..” honors the transcendent worth of each living soul. Like a breath of hope, Farmer’s work sweeps across continents, one person at a time. Joined by Dr. Michael Rich, Partners In Health, and countless others, Farmer has created an elegant and effective model for the delivery of healthcare worldwide.
Developed by Echo student interns, this curriculum guide offers educators and students alike a user-friendly tool with which to access the world of global healthcare. The special chapter by Echo Footsteps Ambassadors to Rwanda provides a window into the experience of twelve Charlotte students who studied the PIH model, Rwandan history and the reconciliation, and then traveled to that extraordinary country to learn first-hand.
Through Echo's unique collaboration with Partners In Health, and Nkondo Primary School in Rwinkwavu, we observed the challenges to equity in healthcare as we experienced the beauty and blessing of bonds that bind us to all people.
With wishes for an inspired and rewarding year,
Stephanie G. Ansaldo, President The Echo Foundation “One by One by One ...... ”
Paul Farmer & Partners In Health
“This is the duty of our generation as we enter the twenty-first century—solidarity with the weak, the persecuted, the lonely, the sick, and those in despair. It is expressed by the desire to give a noble and humanizing meaning to a community in which all members will define themselves not by their own identity but by that of others.” —Elie Wiesel, Nobel Laureate for Peace
This curriculum guide is generously underwritten with a grant by The Everett Foundation
THE ECHO FOUNDATION 1125 E. Morehead St., Suite 106 Charlotte, NC 28204
Foreword
This summer, charged with creating Echo’s 2008-2009 curriculum guide, we observed global human suffering of the severest nature from perspectives of media on six continents. In pictures, we saw tuberculosis patients reduced to diaphanous skin and brittle bones. In words, we heard the despair of women who were infected with HIV/AIDS after being raped by men as familiar as philandering husbands or as distant as enemy soldiers. We challenge you to take a step back and to view the world through the eyes of the impoverished and diseased. We hope that our curriculum convinces you of the urgency and of our collective responsibility to uplift the millions of people who suffer in our world.
Our four core chapters (Ch. I-IV) introduce the subject of global health. The first of these chapters is devoted to Dr. Paul Farmer (Student Dialogue speaker), Dr. Michael Rich (Humanity’s Day speaker), and Partners In Health (PIH)—an organization, co-founded by Dr. Paul Farmer, that ameliorates health conditions in underprivileged regions of the world by holistically addressing the needs of a society. The second core chapter expands on the environment in which PIH works, elucidating the variety of challenges people in the Third World face in attaining health. The third core chapter highlights the initiatives of nations, communities, and organizations that have alleviated health disparities. Our fourth and final core chapter aims to help you better relate to the healthcare crisis abroad by exploring the difficulties in healthcare provision right here at home.
We have included a page of discussion questions at the end of each core chapter to reinforce the themes covered throughout the chapters. The page of discussion questions for both chapters four and five can be found at the end of our fifth chapter “Election 2008,” as the themes for both chapters come together.
Our sixth chapter, “Footsteps in Rwanda,” is a collection of essays and photographs by 2008 Echo Footsteps Ambassadors. They share what they saw first-hand in Rwanda and the impact of the trip on their own perspectives.
We also include classroom activities to facilitate the introduction of global health issues, and we encourage you to explore our resource page in the appendix. The latter links to websites and literature that expand on our curriculum guide.
When you are convinced of the necessity for change, explore the “Activism” and “Election 2008” chapters and use the Internet to find opportunities to act.
Have a wonderful year filled with new discoveries and new opportunities.
With hope,
Caitlin Mullins Xiaoyang Zhuang Student Intern Student Intern
The Echo Foundation 4 “One by One by One……..” Table of Contents
I. Dr. Paul Farmer, Dr. Michael Rich, and the Work of Partners In Health A) Dr. Paul Farmer and Partners In Health [PIH] 1. “Dr. Farmer’s Remedy for World Health: Partners In Health on 60 Minutes” …. 10 2. “The PIH Model of Care” 3. “Partners In Health’s Projects” 4. “Wiping Out TB [Tuberculosis] and AIDS” 5. “Croc Attack: Trendy Footwear Fights Sand Fleas in Haiti” B) Dr. Michael Rich 1. “Breaking Down Barriers”……………………………………………………..… 24 2. “Rwanda Scales Up PIH Model as National Rural Health System” C) Discussion Questions………………………………………………………………………. 29
II. Pathology in the Third World A) Introduction 1. “What is the Third World?”……………………………………………………… 33 2. “AIDS in the World, 2007” 3. “Tuberculosis and MDR-TB [Multi-Drug Resistant Tuberculosis]” 4. “Nets Boost Africa’s Malaria Fight” 5. “Malnutrition Getting Worse in India” B) Social Facets 1. “A Dose of Reality: Women’s Rights in the Fight Against HIV/AIDS”………... 42 2. “HIV/AIDS Delivers Heavy Blow to Third World Education” 3. “Why Girls in Liberia Need to Stay at School” 4. “HIV/AIDS Reduces Children’s Education Chances” 5. “AIDS in Africa: A Quest of Trust” 6. “Refugees Denied Access to Health Care” C) Economic Facets 1. “Brain Drain Hits Poor Countries Hard”………………………………………… 63 2. “Millennium Development Goals (MDGs) Are “Just Words” If Financing Is Not Made Available” 3. “Why Aid Does Work” 4. “Why Aid Doesn’t Work”
(Table of Contents continued)
The Echo Foundation 5 “One by One by One……..” D) Political Facets 1. “Inside Zimbabwe’s Healthcare Crisis”………………………………………….. 73 2. “Nigeria Puts Polio Eradication at Risk” 3. “UK [United Kingdom] Alleges Misuse of Aid Given for Polio Vaccine” 4. “U.N. [United Nations] Confronts Another Sex Scandal” 5. “Report Indicts U.S. Government and Inter-American Development Bank for Violations of the Rights to Clean Water and Health in Haiti” 6. “War Fever: Malaria in Conflict” 7. “Burma Junta Forces Health Workers Underground; Volunteers Risk Their Lives to Dispense Aid” 8. “Congo Ceasefire Brings Little Relief for Women” E) Discussion Questions………………………………………………………………………. 94
III. Healthcare Initiatives in the Third World A) Community Involvement 1. “Community Health Workers”…………………………………………………... 96 2. “Siberian Jail is Champion in TB [Tuberculosis] Fight” 3. “Why Madagascar’s HIV Rates Are Low” 4. “Combating HIV/AIDS, Malaria and Other Diseases Through ‘Edutainment’ in Rwanda” B) Access to Treatment 1. “Drug Patent Rules Must Allow Exceptions for Public Health”………………… 107 2. “WHO [World Health Organization] Promotes New Strategies to Combat Threats to Global Public Health” 3. “User Fees: A Necessary Evil?” 4. “BURUNDI: Side Effects of Free Maternal, Child Healthcare” C) Global Action 1. “WHO [World Health Organization]: New Quick TB [Tuberculosis] Test Rolled Out in Africa”…………………………………………………………….. 117 2. “The $10 Solution” 3. “A Life Saver Called ‘Plumpynut’” 4. “PEPFAR [President’s Emergency Plan for AIDS Relief] Reauthorization Bill Introduced as a Bold Plan to Fight AIDS; Women, Disproportionately Affected by AIDS, Stand to Benefit” 5. “Debt Swap Initiative Kicks Off in Indonesia” D) Discussion Questions………………………………………………………………………. 130
(Table of Contents continued)
The Echo Foundation 6 “One by One by One……..” IV. Delivering Healthcare in the West A) Introduction 1. “The Health Care Crisis”…………….…………………………………….…...... 132 2. “Health Care Crisis: Number of US Uninsured Soars, Along With Big Pharma Profits” B) Healthcare Observed 1. “Free Clinic Helps People Who Need It Most”………………………………….. 138 2. “When Your Local Pharmacist Is In Mexico” 3. “France’s Model Health Care for New Mothers”
V. Election 2008 A) How Does Your Candidate Measure Up in Healthcare Provision? ……………....……….. 146 B) Discussion Questions………………………………………………………………………. 157
VI. Footsteps in Rwanda A) Welcome Letter from Cate Auerbach, Footsteps in Rwanda, Student Intern…………….... 160 B) Footsteps Student Ambassador Pages……………………………………………………… 161 C) Reflections…………………………………………………………………………………. 173 D) WE NEED YOU!: Echo and Nkondo School……………………………………………… 175
VII. In the Classroom A) Debate……………………………………………………………………………………… 178 B) Socratic Seminar…………………………………………………………………………… 179 C) Draw to Promote Awareness………………………………………………………………. 179 D) Analyze a Political Cartoon………………………………………………………………... 180 E) Political Cartoon Sketch…………………………………………………………………… 183 F) Creative Writing…………………………………………………………………………… 184 G) Understanding the Vote Through Rapid Fire Debate (Election 2008)…………………..… 185 H) The Economics of Starting an NGO [Nongovernmental Organization]..…………………. 186 I) Maslow’s Hierarchy of Needs……………………………………………………………... 187 J) Musical and Artistic “Relativism”…………………………………………………….…... 189 K) Refugee Health…………...………………………………………………………………… 190
VIII. Activism A) Fundraising Ideas…………………………………………………………………………... 196 B) Activism Resource Page…………………………………………………………………… 197 C) Help Fight Childhood Malnutrition……………...………………………………………… 198 D) Write to Your Politicians…………………………………………………………………... 199
IX. Appendix A) Glossary……………………………………………………………………………………. 202 B) Resources…………………………………………………………………………………... 209 C) The Echo Foundation Art & Writing Contests..…………………………………………… 210
The Echo Foundation 7 “One by One by One……..”
Caitlin Mullins, 2008 graduate, UNC-Charlotte, and Xiaoyang Zhuang, senior, Providence High School, two extraordinary young people, devoted their summers to the exploration of world-wide equity in healthcare and to the development of this document. Their steadfast commitment to excellence in creating this teaching tool furthers the cause of justice in healthcare equity, as it honors those in despair and those who respond.
The Echo Foundation thanks them warmly and wishes them every success in their future endeavors.
The Echo Foundation 8 “One by One by One……..” I. Dr. Paul Farmer, Dr. Michael Rich, and the Work of Partners In Health
agazine. r. Paul Farmer. From From Paul Farmer. r. ospital-the University of righam & Women’s Washington Alumni Alumni Washington D B H M
A recovered tuberculosis (TB) Dr. Michael Rich, PIH Rwanda patient—treated by Partners In Health’s (PIH) Peruvian affiliate, Country Director. Photo by Echo Footsteps Ambassadors. Socios En Salud (SES)—with her family. From Need Magazine.
Photo by Echo Footsteps Ambassadors.
People whose immune systems have been weakened by HIV are particularly vulnerable to catching TB. The spread of HIV has led to millions of new TB infections—particularly in sub-Saharan Africa—making TB the leading cause of death for people infected with HIV/AIDS. (PIH)
The Echo Foundation “One by One by One……..”
Dr. Farmer’s Remedy for World Health Partners In Health on 60 Minutes
May 4, 2008
Video: http://www.pih.org/inforesources/news/60_Minutes_May_2008.html
Text (from 60 Minutes/CBS News):
The great innovators of our time are said to be the titans of technology—the inventors of the microchip, the founders of Microsoft, the guys behind Google. But far from Silicon Valley another great thinker and innovator is changing the world with far less fanfare. His name is Dr. Paul Farmer.
As Byron Pitts reports, more than 20 years ago Dr. Farmer and a few other great minds created a charity called “Partners In Health.” In the years since, they revolutionized the delivery of healthcare worldwide, saving millions of lives in places where no one thought there was any reason for hope.
“The idea that because you’re born in Haiti you could die having a child. The idea that because you’re born in you know Malawi your children may go to bed hungry. We want to take some of the chance out of that,” Farmer tells Pitts.
Farmer invited 60 Minutes to central Haiti, where he discovered his life’s work 25 years ago. The invitation meant a three-hour, jaw Patient “rooms” are the balcony of the hospital. This is clenching, teeth rattling ride on an unpaved road the largest hospital in Malawi. Public domain picture. from the capital city to the hospital.
If the ride doesn’t break your back, what you see when you arrive will break your heart: the squatter settlement of Cange is one of the poorest parts of the poorest country in the Western Hemisphere.
The desperate need Paul Farmer saw in central Haiti as a young man inspired him and four friends to create Partners In Health. They raised money and built what’s become the largest hospital in central Haiti.
The Echo Foundation 10 “One by One by One……..” Asked how many lives he thinks Partners In Health has saved, Farmer says, “In medicine, we say ‘TNTC,’ too numerous to count.”
What began as a small, understaffed and ill-equipped clinic in 1985, today has 100 inpatient beds, an array of specialists, and three operating rooms. They have nearly two million patient visits a year. And the medical care at the clinic is free. For Farmer, healthcare is a human right. He wants to show the world that children for example don’t have to die of treatable illnesses like tuberculosis or malaria, diseases which they treat every day.
“Do you have any idea how many people around the world die from treatable diseases?” Pitts asks.
“Well probably about ten million a year,” Farmer estimates. “Well, let me just give you some numbers. Just from AIDS, tuberculosis, malaria and women who die in childbirth, I bet that’s six million.”
Haitians are so desperate for medical care that each night people sleep on the ground, outside the hospital, just waiting to get treated. 60 Minutes was there when Farmer got word that a woman dying in childbirth was being prepared for an emergency c-section.
The surgical team was made up entirely of Haitians. Partners In Health staffs its hospitals with as many locals as possible, so they are not dependant on Americans. In this case, the baby was delivered alive. For the mother who’d lost a PIH’s Program On Social and Economic Rights lot of blood, it was touch and go. (POSER) constructs houses for families in poverty. From PIH. Dr. Farmer checked on her after the operation. “She’s gonna make it, thumbs up,” he remarked later.
“That same woman, same circumstances, 25 years ago, what would have happened?” Pitts asks.
“Well, she wouldn’t have made it,” Farmer says.
Asked what that tells him about his work, Farmer tells Pitts, “It tells me that if you set your sights high and if you stick with it, you can make real progress. That’s what it says to me.”
In fact, Farmer has made astounding progress: Partners In Health has expanded and now works in nine countries, including Peru, Russia, Mexico and three countries in Africa. With 6,000 employees worldwide, their budget of $50 million dollars is barely enough to keep it going.
Farmer spends most of his time commuting between the hospitals in Rwanda and Haiti. One of his priorities is to train a new generation of doctors to follow in his footsteps, physicians like David Walton.
The Echo Foundation 11 “One by One by One……..” “I look at you, 31 years old, medical degree from Harvard, could make a gazillion dollars back in the States, and you’re in Haiti. What do you get out of it?” Pitts asks Walton.
“There’s nothing I’d rather be doing with my life,” the young doctor says. “Absolutely nothing.”
And it’s a hard life: seven-day work weeks, including house calls. And a house call in Haiti can mean a hike up the side of a mountain.
“You walk for 30 minutes, walk for an hour, walk for four hours. The patients do it every day, why shouldn’t I do it?” Walton explains.
On the day 60 Minutes was there, Joseph Jeune before (L) and after (R) treatment for HIV/AIDS/TB Walton was visiting 10-year-old co-infection. From PIH/David Walton. Cledene, who is suffering from a damaged heart valve. Her family and neighbors showed up with their list of ailments. There are no short lines in Haiti. Some of Cledene’s siblings were also sick from sleeping on a muddy floor. Including the parents, 12 people sleep in one room.
“In the scheme of poverty in rural Haiti, this is pretty bad around the lower end of the spectrum, 10 kids living in a place like this, no material possessions and a very, very sick child,” Walton remarks.
Even for the well-trained this is difficult. “I can’t imagine, sorry, turning my back on something like this,” Walton says. “Maybe some people can, but I can’t and I won’t. This is my life’s work.”
There was no happy ending for this story. Cledene died not long after Dr. Walton’s house call.
“There are always whispers about programs like this that they can’t outlive the people that founded the place. That when the Paul Farmers move on, Partners In Health will be done,” Pitts says.
“Paul, part of his genius is that he has set up a system that doesn’t depend on his presence or absence. Haiti is run by Haitian physicians. In Rwanda the Rwandan hospitals should be run by Rwandan physicians,” Walton says. “And so when the Paul Farmers of the world aren’t around anymore, this place will still be here providing great care.” Asked if he knows that or just hopes that, Walton says, “I know it.”
But there’s no question that Farmer has been a driving force. Take AIDS, for example: in the late 1990s the disease was ravaging the people of Haiti. Conventional medical wisdom was there is no point in giving AIDS drugs to the poor in Third World countries. But Farmer wouldn’t give up on his patients. He raised money and gave them drugs anyway.
The Echo Foundation 12 “One by One by One……..” Patients, like a man named Joseph, went from being very ill to feeling better. The same kind of transformation happened in patient after patient.
“When Paul started treating people in 1998 in Haiti, everyone said he was absolutely nuts. ‘Impossible. Can’t be done. Forget about it,’” says Dr. Jim Kim, a professor at Harvard Medical School and one of the co-founders of Partners In Health.
“And here we are, you know, not even a decade later, where the goal is to treat every single human on the planet who needs HIV treatment with the right drugs,” Dr. Kim says.
They saved the life of a man stricken with tuberculosis and thousands like him. Farmer and Kim figured out not just a new way to treat multi drug-resistant TB, but a cheaper way to provide the medicine. Their breakthrough has become the new standard and has saved the lives of people around the world.
“You were able to lower drug prices. How is that possible?” Pitts asks.
“I realized very quickly that these are all old generic drugs. There’s no reason for them to be so expensive. So we did some very simple things. We talked to drug procurement specialists who had contacts in India who said, ‘We can make these drugs for [1/100] of the price,’” Kim explains.
But drugs only work if people take them, so Partners In Health came up with the idea of hiring community health workers. The workers, fellow villagers, visit the sick at home every day, making sure they take their medicine. The result, says Farmer, is that their patients with AIDS and TB stay healthier longer than many patients in the U.S. PIH site in Cange, Haiti. From PIH. “Yes, there are people here in central Haiti who get better care for certain diseases than they would in parts of the United States,” Farmer says.
“Come on,” Pitts says.
“No, I’m absolutely serious. I’ve seen it,” Farmer replies.
It’s a program so successful, Partners In Health has exported the model of using community health workers to American communities like Roxbury, Mass.
Farmer’s success has made him a celebrity in the world of global healthcare; he won a MacArthur genius award.
It’s heady stuff for a man from humble means. His mother was a grocery store cashier, his father a school teacher who chose an unconventional lifestyle for his family.
The Echo Foundation 13 “One by One by One……..” Farmer grew up on a bus. “It was actually a bus that had been used to take x-rays in a tuberculosis screening program. You see, this is why I don’t [mind] talking about my biography, because that sounds so neat, right? I lived in a bus,” Farmer tells Pitts.
“Neat?” Pitts asks. “It sounds pretty hardcore to me. Grew up on a bus.”
“Well no, but I mean it was a tuberculosis bus and then later I became a tuberculosis expert,” Farmer explains.
He came from a family of eight. And he said that even though it was crowded on that bus in Florida, he didn’t feel deprived, but rather adventurous.
From the bus, they moved onto a boat, with “a tent in between,” as Farmer explains.
“How did that kind of upbringing shape who you are now, do you think?” Pitts asks.
“Well, you know, when you grow up in those conditions surrounded by affection, but not having a lot of things, ‘cause you can’t put a lot of things for eight people in 28 feet on space, then you get pretty resilient,” Farmer says.
He went from the bus to a scholarship at Duke University, and then to Harvard Medical School where he’s on the faculty. He married a Haitian woman and they have three children.
Though he travels the world, Farmer insists Haiti is home. His services are free, but he still accepts gifts like an occasional rooster.
“Give me the laundry list, the kind of gifts you’ve gotten over the years,” Pitts asks. Partners In Health’s hospital in Cange provides some of the most advanced care and services in Haiti. Wealthy “Yesterday I got two roosters, I got probably patients from Port-au-Prince often will make the drive about a dozen and a half eggs, I got some milk,” of several hours in order to be treated there. From the Center for Public Integrity/Guy-Claude Jean-Baptiste, Farmer says. Jr. Before Pitts left Haiti, Farmer insisted we meet one last patient, Yolette Sanon, a 35-year-old cancer survivor. The chemotherapy worked, and her leukemia is in remission.
“It’s awfully good news for her, so she looks a million times better,” Farmer remarks. And this was the one place the normally in control, even-keeled Paul Farmer revealed that sometimes his work does get to him. It happened when he read Yolette’s thank you letter.
“I want to take this time to show my gratitude to you. If as for me…,” he reads, getting emotional. “I’ll read it to you later.”
The Echo Foundation 14 “One by One by One……..” “This is hard for you sometimes,” Pitts asks.
“You know, it’s a lot,” Farmer admits. “I mean, everybody should have access to medical care. And, you know, it shouldn’t be such a big deal.”
For the sick, the poor, the forgotten in Haiti, Paul Farmer is a big deal. There is a Haitian expression some of his patients use when he’s away: “We miss him,” they say, “like dry earth misses the rain.”
The Echo Foundation 15 “One by One by One……..” Partners In Health
From Partners In Health
Partners In Health (PIH) was founded in 1987, two years after the Clinique Bon Sauveur was set up in Cange, Haiti, to deliver health care to the residents of the mountainous Central Plateau. PIH co-founders had been working in the area for years. The Clinic was just the first of an arc of successful projects designed to address the health care needs of the residents of the poorest area in Haiti. In the 20 years since then, PIH has expanded its operations to eight other sites in Haiti and five additional countries and has launched a number of other initiatives.
The work of PIH has three goals: to care for our patients, to alleviate the root causes of disease in their communities, and to share lessons learned around the world. Through long-term partnerships with our sister organizations, we bring the benefits of modern medical science to those most in need and work to alleviate the crushing economic and social burdens of poverty that exacerbate disease. PIH believes that health is a fundamental right, not a privilege.
The PIH Model of Care Partnering with Poor Communities to Combat Disease and Poverty
The world is focused as never before on averting millions of preventable deaths among poor people living in the developing world. For the first time, substantial funding is available to treat infectious diseases in impoverished settings. Funding alone, though, won’t be enough. For this massive investment to make a real impact on the twin epidemics of poverty and disease, a comprehensive and community-based approach is key.
Partners In Health’s success has helped prove that allegedly “untreatable” health problems can be addressed effectively, even in poor settings. Until very recently, it was conventional wisdom that neither multidrug-resistant tuberculosis (MDR TB) nor AIDS could be treated in such settings. PIH proved otherwise, developing a model of community-based care used successfully to treat MDR TB in the slums of Lima, Peru, and deliver antiretroviral therapy for AIDS in a squatter settlement in rural Haiti. National health authorities in both countries have now significantly expanded these pilot projects. Today, PIH has transplanted and adapted its model of care to the epicenter of the HIV pandemic in Africa, launching projects in Rwanda in 2005 and Lesotho in 2006. Elements of PIH’s community- based approach have been disseminated to and adapted by other countries and programs throughout the world. From PIH.
The Echo Foundation 16 “One by One by One……..” The Five Fundamental Principles of Our Work Are:
1. Access to Primary Health Care A strong foundation of primary care is critical to successfully treating specific diseases, such as AIDS. People seek care because they feel sick, not because they have a particular disease. When quality primary health care is accessible, the community develops new faith in the health system, which results in increased use of general medical services as well as services for more complex diseases. Therefore, PIH integrates infectious disease interventions within a wide range of basic health and social services.
2. Free Health Care and Education for the Poor The imposition of user fees has resulted in empty clinics and schools, especially in settings where the burden of poverty and disease are greatest. Because both health and education are fundamental routes to development, it is counterproductive (not to mention immoral) to charge user fees for health care and education to those who need these services most and can afford them least. PIH works to ensure that cost does not prevent access to primary health care and education for the poor.
3. Community Partnerships Health programs should involve community members at all levels of assessment, design, implementation, and evaluation. Community health workers may be family members, friends, or even patients who provide health education, refer people who are ill to a clinic, or deliver medicines and social support to patients in their homes. Community health workers do not supplant the work of doctors or nurses; rather, they are a vital interface between the clinic and the community. In recognition of the critical role they play, they should be compensated for their work. PIH doesn’t tell the communities we serve what they need— they tell us.
4. Addressing Basic Social and Economic Needs Fighting disease in impoverished settings also means fighting the poverty at the root of poor health. Achieving good health outcomes requires attending to peoples’ social and economic needs. Through community partners, PIH works to improve access to food, shelter, clean water, sanitation, education, and economic opportunities. From PIH.
5. Serving the Poor Through the Public Sector A vital public sector is the best way to bring health care to the poor. While nongovernmental organizations have a valuable role to play in developing new approaches to treating disease, successful models must be implemented and expanded through the public sector to assure universal and sustained access. Rather than establish parallel systems, PIH works to strengthen and complement existing public health infrastructure.
The Echo Foundation 17 “One by One by One……..” Partners In Health’s Projects
From Partners In Health
Peru
USA
Haiti
Russia
Rwanda
Malawi Lesotho
Haiti/Zanmi Lasante
Zanmi Lasante (“Partners In Health” in Haitian Kreyol) is PIH’s flagship project that first started treating patients in the village of Cange in 1985. In 1998, Zanmi Lasante launched the world’s first program to provide free, comprehensive HIV care and treatment in an impoverished setting. Two years later, with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, this pilot effort was expanded across central Haiti and became known as the HIV Equity Initiative. The initiative is now a global model for the delivery of community-based treatment for complex diseases within the context of comprehensive primary care.
Peru/Socios En Salud
Since 1994, PIH’s sister organization in Peru, Socios En Salud (SES), has been treating disease and training community members to provide prevention and care for their neighbors in the shantytowns around Lima. SES is now Peru’s largest non-governmental healthcare organization,
The Echo Foundation 18 “One by One by One……..” serving an estimated population of 700,000 inhabitants, many of whom have fled from poverty and political violence in Peru’s countryside.
Rwanda/Inshuti Mu Buzima
Launched in the spring of 2005, Inshuti Mu Buzima (“Partners In Health” in the Rwandan national language, Kinyarwanda) is the first PIH project in Africa. The project marked our determination to respond to the escalating crisis in global health by bringing the PIH model of care to the continent that is the epicenter of twin pandemics of poverty and disease.
Lesotho/Bo-Mphato Litšebeletsong tsa Bophelo
Launched in 2006, PIH’s project in Lesotho is our second in Africa and our first in a country suffering from extremely high prevalence of HIV. Lesotho’s TB rate is the fourth highest in the world, and TB spreads rapidly and is particularly deadly where many people’s immune systems have been weakened by HIV.
Malawi/Abwenzi Pa Za Umoyo
In early 2007, PIH and its newest partner organization, Abwenzi Pa Za Umoyo (APZU), started treating patients and training community health workers in the southwestern corner of Malawi, one of the poorest and most densely populated countries in Africa. APZU serves about 100,000 people spread over an impoverished rural area about half the size of Rhode Island.
Russia
Partners In Health’s work in Russia has a narrower medical focus over a vastly wider geographical area than any of our other projects. From a base in Tomsk Oblast, Siberia, PIH has been working since 1998, in collaboration with the Russian Ministry of Health, to combat one of the world’s worst epidemics of drug-resistant tuberculosis (MDR-TB). In partnership with the Division of Social Medicine and Health Inequalities (DSMHI) at the Brigham and Women’s Hospital, PIH has focused on improving clinical services for MDR-TB patients in Tomsk while undertaking training and research to catalyze change in treatment of MDR-TB across the entire Russian Federation.
USA/PACT
The Prevention and Access to Care and Treatment (PACT) project serves the sickest and most marginalized HIV patients in Boston. Adapting the accompagnateur model developed in Haiti, PIH’s only domestic healthcare program trains and employs community members to check in on HIV patients on a daily or weekly basis, making sure they attend medical appointments, take their medications and have access to other essential needs and social services. PACT also recruits and trains people from at-risk communities to become prevention and harm reduction leaders, conducting education and support activities with injection drug users to help them avoid becoming infected with HIV.
The Echo Foundation 19 “One by One by One……..” Wiping Out TB and AIDS
From U.S. News and World Report Oct. 31, 2005 By Michael Satchell
As one of six kids who spent part of his boyhood without running water in a converted passenger bus in a Florida trailer park, Paul Farmer has come a lot further than his untraditional beginnings might have predicted.
Farmer may have been born with a plastic spoon in his mouth. But his hardscrabble childhood forged a quicksilver intellect and unstoppable drive. Exposed to the miseries of the world’s poor, he turned his formidable focus, coupled with a genius for innovation, to solving their health problems.
“What set him apart as a young man was his ability to envision things that no one else could. A lot of young people go to places like Haiti and see the desperate conditions, but they feel stymied when it comes to doing something. Paul saw an opportunity, drew up a plan, and saw it through,” says Ophelia Dahl, who went to Haiti with Farmer in 1983 and is now president and executive director of Partners In Health.
Dr. Paul Farmer. From Brigham & Women’s Hospital- Son of a rootless, restless father who bounced the University of Washington Alumni Magazine. from salesman to fruit picker to would-be commercial fisherman, Farmer is a physician and medical anthropologist with a MacArthur “genius” grant on his resume and two Harvard doctorates simultaneously earned. The seeds for his lifework, however, were planted when he was an undergraduate at Duke University, volunteering at Duke’s hospital and in local migrant labor camps where Haitians worked the tobacco and vegetable fields. After graduation, he enrolled in Harvard Medical School and headed to central Haiti, volunteering to work in Cange on the central plateau, a collection of tin-roofed hovels in the poorest region of the poorest country in the West.
Global Model
In Cange, he studied medicine at Harvard long distance, applying what he was learning to his Haitian patients. To support his work, he founded a small, Boston-based charity called Partners In Health in 1987 with fellow Harvard medical student Jim Yong Kim. PIH set up a clinic called Zanmi Lasante, Creole for “partners in health,” which became the settlement’s first community- based healthcare delivery system.
The Echo Foundation 20 “One by One by One……..”
Today, the well-equipped facility, with its operating rooms, blood bank, satellite communications, laptops, and other components of modern medicine, is a global model for delivering public-health services. PIH fights tuberculosis, AIDS, malaria, and other infectious diseases afflicting millions of the poor in Haiti, Peru, Russia, Mexico, Guatemala, Rwanda, and Boston’s inner city. And its approach is unique. Patients receive not only lifesaving medicines and surgical care but also food, clean water, housing, education, and other social services, all delivered by locals trained in nursing skills and paid as community health workers.
This holistic approach by PIH, coupled with revolutionary drug protocols Farmer and Kim developed, proved that patients with drug-resistant tuberculosis could be cured rather than die by the hundreds of thousands each year. PIH’s success in this and in treating AIDS patients has been so impressive that the World Health Organization has reversed long-held policies and now uses PIH treatment models in more than 30 countries.
To the self-deprecating, 46-year-old Farmer, it’s only a modest start. “A small group of British abolitionists in the [19th] century began a movement that said, ‘Slavery is wrong, and we’re going to change it.’ And they did,” he says. “I believe we can convince people that it’s wrong for the destitute sick of the world to die unattended. We can change that, too.”
The Bus to Duke
Farmer considers it a privilege, not a deprivation, that when he was 12 his family Paul Farmer checked out a child recovering in the pediatric took up a peripatetic residence in an old ward at Rwinkwavu Hospital (Rwanda). From The Boston school bus. When the bus was wrecked in an Globe/Eric Neudel. accident, the family moved into a campground tent and then into a jury-rigged houseboat moored in the Gulf of Mexico. Still, says Farmer, his family bonds were loving and strong, and the high school senior class president won a full scholarship to Duke.
Inspired by the writings of Rudolf Virchow, a 19th-century German medical pioneer whom he discovered at Duke, and pushed by his own Roman Catholicism to help the poor, Farmer went to Haiti in 1983, planning to spend a year there. He stayed much longer. When he received his Harvard M.D. and Ph.D. degrees in 1990, the 31-year-old had treated more types of illness and injury than many doctors see over a career.
By the early 1990s, his Haitian clinic had become a well-equipped center, with trained community health agents serving 100,000 people around Cange. Farmer and his staff enjoyed mounting success in treating infectious diseases, spending $150 to $200 to cure TB patients in their homes compared with $15,000 to $20,000 in a U.S. hospital setting. In 1993, the
The Echo Foundation 21 “One by One by One……..” MacArthur Foundation recognized his work with a $220,000 grant that he plowed into his burgeoning program.
Several people shared credit for PIH’s growing success, none more than co-founder Jim Yong Kim, who was born in South Korea and grew up in one of the only two Asian families in Muscatine, Iowa. Like his friend and fellow Harvard student, Kim was a physician and medical anthropologist with M.D. and Ph.D. degrees. Kim focused his energy on helping Farmer design better treatment protocols and badgering U.S. and foreign pharmaceutical companies to cut deals for cheaper and more-effective drugs.
In 1996, PIH faced an outbreak of patients with drug-resistant TB in a Lima, Peru, shantytown. Instead of trying the usual frontline antibiotics, which didn’t work, PIH administered a carefully calibrated regimen of as many as seven other drugs to patients in their homes, along with needed social services. Cure rates exceeded a stunning 80 percent—better than in U.S. hospitals.
Now Farmer and Kim—who later received his own MacArthur genius award—had a larger goal: to wipe out TB throughout Peru and in other developing countries. And they saw no reason that their successful PIH treatment model couldn’t be applied to other catastrophic infectious diseases like HIV/AIDS and malaria. That required serious money. Kim had been building a relationship with the Bill and Melinda Gates Foundation, and in 2000, the foundation gave PIH $45 million.
That was enough to allow PIH not only to launch a nationwide TB offensive in Peru but to establish a pilot project in Russia as well. More funding soon followed. In 2002, PIH received a $13 million grant from the Global Fund for new facilities and equipment for improvements at the Cange medical complex. Last April, the William J. Clinton Presidential Foundation launched a $10 million HIV/AIDS initiative, and PIH is responsible for establishing the first phase in Rwanda. And in September, PIH was awarded the 2005 Conrad N. Hilton Humanitarian Prize of $1.5 million for significantly alleviating human suffering. Jim Kim received a MacArthur ‘Genius’ Award in 2003 and, in Farmer’s heroes are not towering figures; they are “the mothers of 2006, was selected as one of Time families in Haiti or wherever who get up in the morning without magazine’s 100 most influential any food or water or wood for the fire and somehow feed their people. From the Harvard News Office/Justin Ide. kids, plant a garden, go to the market.”
“We’ve proven that people in poor settings with very complex diseases can be treated and cured,” Farmer says, but he is far from satisfied. “We’ve had some victories,” he says. “But if I were truly influential, everyone in the world would have the right to healthcare, food, clean water, other basics. That’s the goal.”
The Echo Foundation 22 “One by One by One……..” Croc Attack: Trendy Footwear Fights Sand Fleas in Haiti
From Partners In Health June 2008
They’re bright. They’re sturdy. They’re trendy. They’re Crocs—the often gaudily colored plastic shoes worn on playgrounds, hospital floors, beaches and hiking trails all across the United States. And as of this month, they’re on the feet of thousands of children, women and men on the central plateau of Haiti.
The sudden popularity of Crocs in poor Haitian communities wasn’t dictated by fashion. It was prescribed by doctors. Going barefoot in the rocky hills and muddy valleys of Haiti isn’t just uncomfortable. It leads to a major public health problem – an epidemic of tungiasis, an infestation of sand fleas that can cause pain, itching, swelling, open sores and, if left untreated, sepsis, tetanus or gangrene.
A Haitian girl styles her So when they learned that 40,000 pairs of Crocs were available, Zanmi new shoes. From PIH. Lasante (ZL, PIH’s partner organization in Haiti) and the Haitian Ministry of Health jumped at the offer. The donation included not only the value of the shoes contributed by Crocs Footwear but all the costs of shipping them from the factory in China to the docks in Port-au-Prince.
The initiative was orchestrated by Kageno Worldwide, a non-profit dedicated to “transform[ing] communities suffering from inhumane poverty into places of opportunity and hope.” Kageno solicited the shoes from Soles United, Crocs’ program for donating shoes made from recycled material. They also negotiated steeply discounted shipping terms with Cargo Services and arranged to split the costs of the shipping with Pearson Publishing. Brothers Brother, another nonprofit, took charge of getting the shoes into a container and onto the dock. ZL and the Ministry of Health assumed responsibility for distributing the shoes through mobile clinics.
Frank Andolino of Kageno traveled to Haiti to witness the beginning of distribution first-hand. In an email to A Zanmi Lasante doctor examines a other contributors, he reported: “I wish you all could be patient’s feet for signs of sand flea here! It has been amazing. 10,000 pairs of CROCS have infestation. From PIH. safely made it from China to Haiti and 4,000 individuals have already benefited from your generosity.”
The Echo Foundation 23 “One by One by One……..” Breaking Down Barriers A Profile of Michael Rich, MD, MPH
From Brigham and Women’s Hospital Feb. 10, 2008 By Rachel Knott
Michael Rich, MD, MPH never had any intentions of practicing medicine in the United States. From the time he decided to become a doctor, he knew he would work abroad. As a Peace Corps volunteer in Cameroon, West Africa, Rich had just graduated from college when he had the first inkling of what would eventually become his life’s work.
“I was a teacher in Cameroon, and in the two years that I spent there, four of my students died of infectious disease. I myself was sick a number of times, and it really affected me to think that a disease like malaria, which is so simple to cure, can still prove fatal in certain parts of the world. To me, the idea that a short regimen of tablets can wipe an infection from your system over the course of a few days Michael Rich with HIV+ children at the was really impressive. I thought to myself that if I could do PIH chapter in Rwinkwavu, Rwanda. anything, I’d like to come back to areas like Cameroon and From The Echo Foundation. help them out with healthcare.”
Rich’s commitment to helping people in places like Cameroon was so strong that he created a backup plan to becoming a physician. “Because I hadn’t gone pre-med in college, I decided to work as a carpenter for my dad while I prepared to go to medical school. I figured that if I got in, I could do international health. And if I didn’t get in, then I could go to poor countries and build.”
In 1993, Rich graduated from the University of Massachusetts Medical School in Worcester. He completed his residency at St. Vincent’s Hospital in New York City, and after a short period of time working at the Lynn Community Health Center north of Boston, he began volunteering for Doctors Without Borders, or Médecins Sans Frontières (MSF). Advertisement for a traditional healer in Cameroon. Public domain “At MSF I ran a tuberculosis program picture. in Uzbekistan that followed the World
The Echo Foundation 24 “One by One by One……..” Health Organization (WHO) protocol. At the time, the practice was to send anyone who failed first-line drug treatment into hospice care. I thought to myself, this just can’t be right—there has to be someone out there who is doing something about this. As it turned out, the only people who were doing something about it were Paul (Farmer) and Jim (Kim). When I came back to do my Masters in Public Health at Harvard, I made it a point to introduce myself to them.”
Since joining Partners In Health (PIH) in 2001, Rich has become one of a handful of specialists in the treatment of multi-drug resistant tuberculosis (MDR-TB). Currently, there are 2,000 MDR-TB patients under treatment at Socios en Salud, PIH and the Division of Social Medicine and Health Inequalities’ Peruvian affiliate. By comparison, the whole of the United States sees approximately 500 patients per year. To Rich, however, tuberculosis is more than a clinical specialty. Thanks to the success of PIH’s work in Haiti, Russia and Peru, tuberculosis has come to serve as a vehicle by which he and his colleagues are able to address broader issues of social justice and health inequality.
“I like to think of my area of expertise as organizing programs and delivering healthcare to poor populations. In Peru, we provide a lot of direct patient care, but we also act as a consultant to the manager of the national TB program. Helping to get them funding, and to train the doctors and nurses to be TB experts as well, is essential to the sustainability of the program. In Russia, we have similar goals and tend to divide our time between training clinicians and spending time at the sites trying to find solutions to difficult clinical cases.”
Rich’s efforts to build a TB treatment model lead him into international health policy circles as well. As a member of the WHO’s TB/HIV and Drug Resistance Unit’s working group, he is tackling the important task of writing new guidelines for the WHO on the treatment of MDR- TB.
“By taking what we’ve learned at PIH and translating it into practical policies, we’re writing an extensive, consistent manual on how to treat tuberculosis.”
But despite all of his successes, Rich’s job remains a challenging one.
“You’ll be driving through Lima and see hill after hill covered with shacks. You know they don’t have running water, and there’s only one little electrical wire for the whole region, and you wonder what is ever going to change this? Sometimes it’s overwhelming, the economic, political and social forces that are against you. You’re away from your family a lot, you’re traveling all the time, and you think to Slums in Lima, Peru. From Wikimedia Commons/ Hakan yourself, the ocean’s so big and our boat is so Svensson. small—how can this ever be done?”
Fortunately, the number of people who are making global health equity a priority is increasing. Institutional affiliations, such as those between PIH, Harvard Medical School and Brigham and
The Echo Foundation 25 “One by One by One……..” Women’s Hospital, draw attention to the importance of the work of Rich and his colleagues at the DSMHI [Department of Social Medicine and Health Inequalities].
“I’m very proud to tell people why the DSMHI was created. It was created because Brigham and Women’s Hospital cares about fighting HIV and TB—not only in their catchment area, but also throughout the world. Most doctors I know would like to have a part in international health, but it’s difficult to make a lifetime commitment to this type of job. At the DSMHI, we’re breaking down some of the barriers that stand in the way.”
Still, the demands and personal sacrifices of international health are daunting. Michael Rich just shrugs it off.
“People ask me how I work so hard, but when I’m over there in Tomsk (Russia), it isn’t work, it’s my life. My colleagues are also my friends, and it’s an incredible privilege to feel that your work has meaning. We do make progress. We save lives and we make people’s lives better. It’s a wonderful job.”
The Echo Foundation 26 “One by One by One……..” Rwanda Scales Up PIH Model as National Rural Health System
From Partners In Health, 2007
Inshuti Mu Buzima (IMB), PIH’s partner organization in Rwanda, has accomplished a great deal during its first two years of work in two destitute rural health districts. It has enrolled more than 2,500 HIV patients on antiretroviral therapy, trained and hired more than 800 villagers as com- munity health workers, and recorded nearly 100,000 patient visits in 2006.
As a reward for their hard work and success, IMB and their partners in the Rwandan Ministry of Health and the Clinton Foundation have now committed themselves to an even more daunting and inspiring challenge—to make IMB’s approach to delivering comprehensive, community- based care the model for Rwanda’s national Rural Health system. Plans have already been drafted to extend the model first into the districts most in need of services and then to all 27 districts and 9 million residents of rural Rwanda.
PIH’s model has already been replicated around the world, says Dr. Michael Rich, PIH’s country director in Rwanda. “However, there’s a difference between replication and scaling up,” he says, a difference in sheer magnitude. “So how do we go from replication to a countrywide scale- up?” World AIDS Day at Rwinkwavu Hospital in Rwanda. From PIH. Instead of PIH finding and training staff and procuring equipment and facilities, the focus will be on training Rwandans to replicate the model, and then creating a “critical mass” of people who can teach the model to other areas, says Dr. Rich. The goal is for PIH to work mainly as facilitators, helping the Rwandan government meet its own national health goals, which are addressed as part of this rural health scale-up.
“What’s especially exciting about this is that the Ministry of Health is committed not just to scaling up treatment for HIV, which would be great, but to our entire comprehensive, holistic approach that considers the dignity of the patient,” said Dr. Blaise Bucyibaruta, who heads up pediatric HIV programs for IMB. “We do whatever it may take,” he added. “That includes ensur- ing that poor people have access to care, training community health workers well and paying them fairly, and making sure that patients and their families have enough food to eat, access to education, and a means to generate income.”
All of these dimensions of the PIH model are included in a set of 10 principles that PIH and their partners in the Ministry of Health have established for the national scale-up (see box, page 4). These principles commit the partners to provide: Comprehensive health care, available to all; Relentless focus on the patient and quality of care, regardless of the challenges of the environment; A community-based model, decentralized where possible from hospital to health
The Echo Foundation 27 “One by One by One……..” center and from health center to patients’ homes; Holistic care for the community beyond the purely clinical, including food, education, clean water, and income generation projects.
The plan will be launched in four of the neediest districts in 2008 and will then be rolled out to all 27 rural districts across the entire country. Work in each district will include four levels of involvement: at the district hospital, health centers, health posts, and with the community health workers.
Finding the resources—both human and financial—remains a huge challenge for the scale-up, says Dr. Rich. For example, there are cur- rently only about 3,000 nurses in all of Rwanda. “That’s one limitation,” he says. “It would really take about 6,000 nurses” to staff the scale-up, backed by all the funding needed to train and pay them. Rwandan children replicate the PIH logo. From PIH. “Right now in Rwanda, very little money gets spent on health, maybe only a couple of dollars per year [for each person living in a rural area],” Dr Rich continued. “We want to increase that almost ten-fold, to about $23 to be spent on that person for health care.” Although that would represent a steep increase in spending, it pales in comparison to current U.S. health spending of about $6,700 per person. More importantly it fits within the plans and commitments of the Rwandan government and falls below the targets endorsed by the African Union of spending $34-$40 per capita and 15 percent of national budgets to provide essential health services.
Dr. Agnes Binagwaho, who heads Rwanda’s National Commission to Fight AIDS, emphasizes that the scale-up is a necessary and affordable component of “a development process that includes the most vulnerable.”
“Our institutions seek to transform Rwanda from a poor country to a middle-income country,” she explained. “This transformation takes place by developing high-quality care that is available equitably across our country. That’s why the model called ‘Rwandan rural health care’ is seen as a necessary step towards rapid development, fair and shared by all. I also support this effort because it has already been implemented in two districts and has shown us that it is possible, a sount investment, efficient, and necessary for sustainable development. Some of the money is already in the country, from the government’s existing $100 million national budget for health care, and from NGOs and other funding sources. Some of these resources can be directed towards the scale-up strategy, says Dr. Rich. “But we will still have a ways to go.”
As for medical workers, many locals can be trained and employed as community health workers to ease the workload for nurses, which will also contribute to the goals of providing income- generating opportunities and strengthening local economies. But this form of task-shifting will only stretch so far. In all, estimates put the cost of the program at about $200 million per year nationwide.
Scaling up resources to that level and extending comprehensive, community-based care throughout rural Rwanda will not happen overnight. But hope abounds. Manzi Anatole, a Rwandan nurse working with IMB radiates his excitement over the planned scale-up, “We have many challenges,” he says, “But we want to show the people of the village, the province, the country, the world, that such things are possible.”
The Echo Foundation 28 “One by One by One……..” A note on the discussion questions:
We have included three discussion questions’ pages to correspond to our chapters in the curriculum guide. We have included an additional discussion questions’ page that addresses healthcare in the United States—pulling from both our “Delivering Healthcare in the West” and “Election 2008” chapters. This discussion questions’ page can be found at the end of the “Election 2008” chapter. The questions for each discussion questions’ page are derived from the material discussed in the articles, and they are compiled to provide a review of the concepts in each chapter.
Chapter One Discussion Questions
1. In his 60 Minutes interview, Dr. Paul Farmer explains “that because you’re born in Haiti you could die having a child … [or] Malawi your children may go to bed hungry. We want to take some of the chance out of that.” What does Dr. Farmer mean by this? What does it reveal about his goal for PIH?
2. Why does Dr. Farmer employ local people in PIH hospitals?
3. Why would Dr. Farmer devote his life to work in the Third World when he could easily live a very comfortable life in the First World?
4. Why do you think it is effective to combat disease and poverty (“twin epidemics”) with a comprehensive community-based approach?
5. What are the components of community-based care? (e.g. hiring community workers instead of foreign expatriates.) Why are these components more effective?
6. Do you believe healthcare is a privilege? Why or why not?
7. Why did PIH hire community workers to visit patients every day? Why is this important?
8. Why did health professionals in the developed nations believe it was impossible to treat patients who had HIV/AIDS or multi-drug resistant tuberculosis in developing nations?
9. In the “Partners In Health” article (p. 16), five principles of PIH’s work are discussed. What are these five principles? Explain their significance.
10. Where are some of the places that PIH operates? What do all these places have in common? Why does PIH choose them?
The Echo Foundation 29 “One by One by One……..”
The Echo Foundation 30 “One by One by One……..” II. Pathology in the Third World
ue. g
ricaLo f
rica. From SouthA From rica.
sangoma, or traditional healer, in South A Af
Washed garments drying in A supporter of Zimbabwe’s Siem Reap, Cambodia. High opposition Movement for concentrations of malaria Democratic Change (MDC) cases are located here. From lays in a hospital in Ruwa. National Geographic-Nic From the AFP/Getty Images. Cleave Photography.
17-year-old Sita from Nepal delivers her first child. The baby is seriously ill. From UNICEF.
In Southeast Asia, the Cytomegalovirus (CMV) causes HIV/AIDS victims to be permanently blind. Treatment is available, but the drug—manufactured by Hoffman-La Roche—costs $10,000 per patient. Because patients and aid agencies cannot afford this drug, patients are unable to contribute to their own livelihoods and their local economies, perpetuating a cycle of poverty (MSF, 2008)
The Echo Foundation “One by One by One……..” What Is the Third World?
From Dictionary.com
the underdeveloped nations of the world, especially those with widespread poverty.
From the American Heritage Dictionary of the English Language, Fourth Edition
the developing nations of Africa, Asia, and Latin America.
From World Book Online Encyclopedia By W. Scott Thompson A community in Rwanda. From the Female Health Co. As early as the 1950’s, economists used the term Third World to mean the poor countries of the world. Over time, this economic meaning became the more common one, especially following the end of the Cold War in 1991.
Economically, a typical Third World nation has a shortage of food, few sources of power, and low annual per capita (per person) income. Per capita income, often called PCI, is the entire income for a nation in a given year divided by that nation’s population. Most Third World countries have an annual PCI of less than $1,000. Many have an annual [per person income] of only a few hundred dollars. By contrast, many developed nations have a PCI of more than $20,000 per year.
The economic Third World in the early 2000’s was made up of about 50 countries that held more than half the world’s population. Almost all Third World countries had economies based on agriculture. Less than half had developed a significant base for modern industry.
The Third World has a majority of the votes in the General Assembly of the United Nations, but as a political bloc, the Third World has lost coherence. By the late 1980’s, many nations that were once in the Third World had become wealthier. For example, the five countries that economists call the BRIMC nations—Brazil, Russia, India, Mexico, and China—as well as many countries in Southeast Asia, became developing countries. Their increase in wealth caused a shift in perspective that made them less likely to agree with the political goals of Third World nations. As more Third World nations entered the ranks of developing countries, Africa, by far the poorest continent, became the focus of Third World political and economic attention.
International organizations provide funds for development in the Third World, but progress in improving the quality of life for people there has been slow. Some of the problems that economists believe prevent the Third World from prospering include rapid population growth, high rates of disease, a lack of educational opportunities, political corruption and government mismanagement, and violent conflicts.
The Echo Foundation 32 “One by One by One……..” AIDS in the World, 2007
From The Boston Globe Dec. 1, 2007
Last week, the lead United Nations agency in the fight against AIDS announced that for several years it had been overestimating the number of people infected with HIV, the virus that causes AIDS. The number of new infections, officials at UNAIDS declared, likely peaked around 1999. This news is welcome, but it should not lead to any weakening of financial support or social commitment to the global fight against AIDS.
Even with the lowered estimate, UNAIDS still believes that 33.2 million people, down from 39.5 million, are infected. Only a small minority in developing countries are getting the best drug treatments.
Meanwhile, recent news on the vaccine front has been discouraging. Recently, Merck announced that a vaccine it had been testing had failed. Indeed, it actually raised a person’s risk of infection. The difficulty of developing a vaccine against HIV puts a premium on the best available means of preventing infection. The “ABC” strategy—Abstinence, Being faithful to one partner, and Condoms—remains the A Kenyan grandmother has been left to fend for best hope of keeping the number of people with HIV orphans after her own children died of AIDS. From Reuters/Antony Njuguna. from rising.
Past UNAIDS figures overstated that number because the agency’s data were based largely on the testing of pregnant women in urban clinics. Researchers now believe that extrapolating from those results was a mistake, because, they say, patients in urban settings are likely to have more sex partners than rural women and thus are more likely to be infected. To get more accurate figures, researchers financed by the US Agency for International Development have chosen households at random in urban and rural areas and deployed health workers to collect medical and lifestyle histories and blood samples.
The information gleaned from such surveys can be invaluable, not just in gauging the state of the epidemic but also in figuring out how to deal with it. In parts of sub-Saharan Africa where a high percentage of people are HIV-positive, one important factor in lower rates of new infections appears to be more fidelity in sexual relationships, according to Paul De Lay, the director of evidence, monitoring, and policy for UNAIDS.
An emerging hypothesis for the high prevalence of AIDS in sub-Saharan Africa is that, while people there have roughly the same number of sexual partners over a lifetime as people elsewhere, it is more common there for a man to have a sexual relationship with two or more
The Echo Foundation 33 “One by One by One……..” women at the same time. A person who is newly infected with HIV has a high viral load in the first month or so and is especially likely to transmit the disease to partners. For this reason, according to Helen Epstein, a public health specialist and former AIDS vaccine researcher, “overlapping relationships” are riskier than consecutive ones.
Someone who has as few as one long-term sexual partner, Epstein has noted, is at risk of infection if that partner has another long-term partner who is on, as she puts it, the “HIV superhighway.” In a teleconference this week, Epstein said it is important to get this information to people, so that they will “have an understanding of where the real risk comes from.”
This hypothesis also points to the importance of raising the status of women so that they do not have to enter such overlapping relationships for economic reasons, and, if they are in such relationships, can insist on the consistent use of condoms. A study in 2004 and 2005 by Physicians for Human Rights found that lack of control by women over sexual decision-making was a major factor increasing their vulnerability to the disease. In sub-Saharan Africa, 61 percent of those with AIDS are women. Scanning electron micrograph of HIV-1 budding from cultured lymphocyte. From the CDC. De Lay, the UNAIDS official, cited other factors besides increased fidelity to one partner that have likely played a role in reducing infections, such as more frequent use of condoms by prostitutes and other high-risk groups, and more attention to other sexually transmitted diseases, which if untreated can increase a person’s vulnerability to HIV.
The improved surveys on HIV infection rates by health workers have another benefit: They can also alert officials to any tendency among individuals who have access to effective antiretroviral drugs to engage in risky sexual behaviors or to be more willing to use intravenous drugs with contaminated needles. De Lay said researchers are finding that, in both the United States and Uganda, the transformation of AIDS into a chronic, largely treatable disease is leading more people to return to unsafe practices.
Officials and grass-roots public health workers alike must fight this attitude. While promising evidence suggests that new infections have declined in recent years, the trend will only reverse if broader access to HIV drugs makes the infection appear to be a risk worth taking. Defeating AIDS requires the best drugs and the best prevention strategies, buttressed by the best research on what is working and what is not. Paying for this will continue to require generous support for the Global Fund to Fight AIDS, Malaria, and Tuberculosis, and this country’s own international program of AIDS relief. The new calculations must prove to be not just a statistical blip, but a long term trend to greater survival.
The Echo Foundation 34 “One by One by One……..” Tuberculosis and MDR-TB
From Partners In Health
A curable disease that kills millions in the developing world, tuberculosis offers a glaring example of global inequalities in access to health care. Drugs to fight tuberculosis (TB) have been in existence for 50 years, and deaths from TB are rare in rich countries. Yet TB kills 5,000 people every day, nearly 2 million people per year. More than 2 billion people, almost one-third of the world’s population, are infected with the microbes that cause TB.
TB and HIV/AIDS
In recent years, the tuberculosis epidemic has intensified alongside another global plague of the poor: HIV/AIDS. People whose immune systems have been weakened by HIV are particularly Hospital Domingo Olavegoya in Jauja, Peru, famous vulnerable to catching and dying from TB. The for the treatment of tuberculosis. Public domain spread of HIV has led to millions of new TB picture/Hakan Svensson. infections—particularly in sub-Saharan Africa—making TB the leading cause of death for people infected with HIV/AIDS. Because of this destructive relationship, the PIH model of care for HIV emphasizes coordination with expanded calls for aggressive treatment of tuberculosis in people living with HIV/AIDS.
Drug-Resistant TB
If TB patients in treatment do not take each medication at the prescribed time or are unable to complete the full course of treatment, their tuberculosis may become resistant to those medications. To avoid the development of resistant TB, patients typically take TB medications under the supervision of health workers, a method known as Directly Observed Therapy, or DOT.
Over the past 15 years, however, incomplete TB treatments—due to shortages of medicines and medical personnel, civil disruptions, and socioeconomic barriers for patients—have led to a proliferation of strains of tuberculosis resistant to two or more TB medications. These strains, known as multi-drug resistant tuberculosis, or MDR-TB, are now present throughout the world. MDR-TB can be treated and cured. But treatment regimens are complicated, lengthy and expensive. Medications that are currently available can produce crippling side effects and are less effective than drugs for non-resistant TB. If left untreated, however, MDR-TB not only kills the patients but can spread to other people, where it may develop additional drug resistance.
Extremely virulent strains of tuberculosis (XDR-TB) that are resistant to three or more of the second-line drugs used to treat MDR-TB have reached epidemic proportions in several areas. One outbreak in KwaZulu-Natal, South Africa, killed 74 of 78 patients within a matter of weeks,
The Echo Foundation 35 “One by One by One……..” sparking fears that XDR-TB could spread rapidly and lethally, particularly in areas with high prevalence of HIV infection. In September 2006, the World Health Organization issued an alert regarding the emergence of XDR-TB.
Leading the Fight Against MDR-TB in Peru and Russia
PIH has been a world leader in developing and demonstrating the effectiveness of clinical regimens and community-based strategies for combating MDR-TB in resource-poor settings. In partnership with our sister organizations in Peru and Russia, PIH has published clinical care manuals for management of MDR-TB in English, Spanish and Russian. And PIH continues to advocate for expanding access to treatment for TB, and for development of new, more effective drugs to combat the disease.
When an epidemic of MDR-TB was discovered in the shantytowns of northern Lima, Peru, in 1996, PIH and its Peruvian affiliate, Socios En Salud (SES), initiated the world’s first community-based treatment program for MDR-TB in a resource-poor setting. SES was the lead organization in this effort, which created a treatment strategy to cure patients infected with MDR-TB and stop ongoing transmission. At a time when the World Health Organization (WHO) and the Peruvian Ministry of Health considered treatment of MDR-TB impractical and unaffordable, SES trained and hired people from the community to accompany patients through the long and arduous course of treatment with difficult-to-obtain second-line drugs. The result was a comprehensive approach to MDR-TB that enhanced access to care and achieved one of the highest cure rates for MDR-TB ever reported, an astonishing 83 percent.
The success of Socios En Salud’s patients in Peru made a powerful case for treating MDR-TB in developing countries. In 2002, the WHO agreed and began approving treatment plans for MDR- TB on a country-by-country basis. Four years later, in 2006, new guidelines for treatment of MDR-TB were released jointly by the WHO and other leaders in the fight to stop TB, including the U.S. Centers for Disease Control and Prevention and PIH. The guidelines were accompanied by a plan to increase the number of MDR-TB patients receiving treatment worldwide from 16,000 in 2006 to a total of 800,000 by 2015.
The new guidelines for treatment of MDR-TB were also influenced by research documenting the success of PIH’s MDR-TB program in Siberia. Russia’s epidemic of drug-resistant tuberculosis is among the worst in the world. In Tomsk Oblast, Siberia, where PIH has been working since 1998 to expand the MDR-TB model developed in Peru, 14 percent of patients newly infected with TB are multi-drug resistant. The TB epidemic is especially complex in the prison system, where drug resistance is even more prevalent.
PIH-Russia has worked to strengthen MDR-TB care for patients, particularly those in prisons, by renovating TB hospitals, training medical personnel, and distributing educational materials on MDR-TB throughout the former Soviet Union. By February 2005, the first group of MDR-TB patients in Russia had achieved a 78 percent cure rate, and nearly 1,700 TB and MDR-TB patients had received support from PIH-Russia. PIH-Russia and Boston staff have also worked to develop and carry out a research agenda that has demonstrated the effectiveness of treatment and disproved theories that adding treatment for MDR-TB would undermine the standard Directly Observed Treatment, Short Course (DOTS) program for non-resistant TB.
The Echo Foundation 36 “One by One by One……..” Nets Boost Africa’s Malaria Fight
From BBC News Oct. 17, 2007
Countries in sub-Saharan Africa are making significant progress in fighting malaria, new statistics from Unicef and the World Health Organisation show.
Distribution of mosquito nets, widely regarded as the most effective prevention against malaria, has grown substantially across the region. In countries where they From The New York Times/Mariella Furrer. are used, malaria deaths have dropped by half. But even with some progress, about 800,000 African children under five still die from malaria each year.
Sixteen of 20 sub-Saharan countries report that the number of children using the mosquito nets has tripled since 2000.
The new report from the UN children’s fund reveals that since 2004 the annual production of bed nets has more than doubled, from 30 million to 63 million.
In Gambia, half of all children now have bed nets. Ethiopia has distributed 18 million in the last two years alone. The report also finds that national health programmes in malaria-endemic countries have benefited from a tenfold increase in international funding in the last decade.
Drug Shortage
But while Unicef and the WHO are pleased with the progress in preventative measures, the death toll among African children remains unchanged. Every year, 800,000 African children under the age of five die from malaria. Meanwhile, fewer children are receiving life-saving drugs if they do get malaria. This is because most African countries have followed WHO advice and phased out older treatments which had become ineffective—but have not yet brought in the newer, more expensive malaria treatment drugs. But, the WHO says, increased production of the new treatments is now bringing prices down.
Since 2003, artemisinin-based combination therapies (ACTs) have become the norm for use in national health programmes, according to the Unicef report. “Still, it’s a minority of children that get access to the best types of antimalarials,” the chief of global health for Unicef, Dr. Peter Salama, said. “But with the strong backing of some of the international donors and the price of ACTs starting to be reduced, I think governments are becoming more confident now that this will be a sustainable strategy for antimalaria treatment in the future,” he added.
The Echo Foundation 37 “One by One by One……..” Malnutrition Getting Worse in India
From BBC News June 10, 2008 By Damian Grammaticas
Lying on a bed is a tiny malnourished child. Her limbs wasted, her stomach bloated, her hair thinning and falling out. Her name is Roshni. She stares, wide- eyed, blankly at the ceiling. Roshni is six months old. She should weigh 4.5kg. But when she is placed on a set of scales they settle at just 2.9kg.
Roshni is suffering from severe acute malnutrition, defined by the World Health Organisation as weighing less than 60% of About 60% [of] children in Madhya Pradesh state are malnourished. From BBC News. the ideal median weight for her height.
There are 40 beds in this centre. On every one is a similar child. All are acutely malnourished. Wailing, painful, plaintive cries fill the air. This is the Nutrition Rehabilitation Centre in the town of Shivpuri.
You might think we are somewhere in Africa. But this is the central Indian state of Madhya Pradesh—modern India, a land of booming growth.
“The situation in our village is very bad,” says Roshni’s mother, Kapuri. “Sometimes we get work, sometimes we don’t. Together with our children we are dying from hunger. What can we poor people do? Nothing.”
Typical Symptoms
The lunchtime meal of boiled eggs, milk and porridge is handed out. Another mother is cradling her daughter, trying to Roshni weighs 2.9kg—her weight feed her. The girl’s name is Kajal. She is two-and-a-half years should be more like 4.5kg. From BBC old and so weak she can hardly eat. Her mother tries to spoon News. some milk into her mouth. It dribbles down her chin.
Kajal barely even opens her eyes. Kajal’s skin is pale. Her breath comes sharp, shallow and fast. She too is suffering from severe acute malnutrition. Her weight is 6.7kg.
The Echo Foundation 38 “One by One by One……..” The nutrition centre here was set up by the United Nations Children’s Fund (Unicef). Doctor Vandana Agarwal, Unicef’s nutrition specialist for Madhya Pradesh state, points to Kajal’s swollen little feet. “There is oedema on both the feet, scaly skin on her legs, even her respiration rate is high,” Dr. Agarwal says. “The child is in a lethargic condition, her hair is thin, sparse, lustreless, easily-pluckable. These are the typical symptoms of protein energy malnutrition.”
India has some of the highest rates of child malnutrition and mortality in under-fives in the world and Madhya Pradesh state has the highest levels in India. There are around 10 million children in the state. A decade ago 55% were malnourished. Two years ago the government’s own National Family Health Survey put the figure for Madhya Pradesh at around 60%. So why is it going up?
Compounded
“It’s basically inadequate access to food, poor feeding practices, poor childcare practices,” says Dr. Agarwal.
In Madhya Pradesh the situation is compounded by two Children wait for a meal outside an significant factors. For four years in a row the rains have Anganwadi centre in Chitori Khurda. failed, so food crops have failed too. And now global food From BBC News. prices have risen, stretching many families beyond breaking point. “In the past year food prices have increased significantly, but people’s incomes haven’t improved,” says Dr. Agarwal. “Like wheat, earlier they used to buy it at eight rupees a kilogram, now it’s 12 rupees.”
“Because of the increase in food prices a mother cannot buy an adequate quantity of milk, fruits and vegetables. So their staple diet has become wheat chapattis,” she explains.
“A child cannot survive on wheat chapattis alone. About 80% of mothers and children are anaemic because they can’t get good quality food.”
To see why things are so bad, we headed out into the villages around Shivpuri. The drought zone stretches across this part of central India. The land is parched and barren. The air hot and heavy.
The village of Chitori Khurda is a ramshackle collection of 80 stone and mud huts on a rocky plain. The villagers here come from the bottom rung of India’s social scale. Among the lowest of the low in India’s caste system are the Scheduled Tribes, just above them come the Other Backward Castes. Together they make up 95% of the population of Chitori Khurda.
Worst Hit
Even here, in this desolate spot, caste matters consign the lowest to the harshest existence.
Chitori Khurda village has no water supply. There are four wells in the fields around, but all belong to higher caste owners who often refuse to let the villagers use them.
The Echo Foundation 39 “One by One by One……..” So these are the people worst hit by rising food prices. They have little land of their own. What they do have is the least fertile, sometimes far away. Without water they cannot irrigate, so they cannot feed themselves. And out here there is not much in the way of work either.
The men of Chitori Khurda get odd jobs labouring for higher castes or just play cards all day. The women sit outside their houses sorting green leaves they have gathered into small bundles. The leaves are sold to make local cigarettes. But it does not earn much.
So in almost every home people are going hungry. Unicef says 79% of the children in this village are malnourished.
Siya showed me her house, crouching to get in through the low door, we entered a stifling-hot, single room where the family of six live. Siya picked up the can where she keeps her flour. It should hold enough for a week’s supply. There were just a few cupfuls left.
Her two youngest children, seven-month-old Anjali and two-year-old Aseel, are both severely acutely malnourished. The family can afford to eat only twice a India has some of the highest rates of day. The children chewed slowly on a few chapattis child malnutrition in the world. From flavoured with a tiny bit of onion and ground chillies. It is BBC News. all they have to eat.
Getting Worse
Siya’s husband works as a bonded labourer. He is still trying to pay off a loan he took out 15 years ago.
In theory the government provides 30kg of subsidised flour a month to every poor family. But corruption and inefficiency mean the system often does not work.
Even with the full allocation a family like Siya’s would have to buy an additional 90kg of flour a month at a cost of more than 1,000 rupees.
Siya says several days a month the family has to go to bed hungry. “The children cry and create a commotion,” she tells me. “I go door-to-door until somebody gives me a little.”
Every lunchtime the children of Chitori Khurda gather at the Anganwadi centre in the village. It is where nutrition and health services are provided at village level.
On the day we visited, each child was given two puris (small bread puffs fried in oil) along with some sweet porridge. The allocation is 80g of food a day per child. The children ate it, then sat hoping for more, but there was none.
The Echo Foundation 40 “One by One by One……..” Madhya Pradesh is trying hard to tackle the problem of malnutrition, but it is getting worse, not better. Corruption and inefficiency hamper the system. Some Anganwadi workers skim off food to sell. Others refuse to give food to lower-caste children. Many simply do not turn up as they are not paid much for the job. Add to that high food prices and the poorest are sliding into hunger.
Back in Shivpuri, two-and-a-half-year-old Kajal had to be transferred to hospital. Her condition was so serious, she was so anaemic and her haemoglobin levels so low that she had to have an emergency blood transfusion. Lying in her hospital bed Kajal was reviving, slowly. Her mother, anxious, looked on, a pressing question weighing on her mind.
Kajal should survive, but how will she feed her child? Doctors say inadequate access to food is one of the causes of malnutrition. From BBC News.
The Echo Foundation 41 “One by One by One……..” A Dose of Reality Women’s Rights in the Fight Against HIV/AIDS
From Human Rights Watch Mar. 25, 2005
The global HIV/AIDS pandemic is taking a catastrophic toll on women and girls. The number of HIV infections among women and girls has risen in every region in recent years, and in sub- Saharan Africa, women and girls constitute nearly 60 percent of those living with HIV. In some countries, the HIV infection rates for girls are many times higher than for boys. The rising number of HIV infections among women and girls is directly related to violence against women and their unequal legal, economic, and social status.
Abuses of women’s and girls’ human rights impede their access to HIV/AIDS information and services, including testing and treatment. Those who do obtain HIV services sometimes face disclosure of their confidential HIV test results by public health officials without the women’s consent. This Chameli, 30, travelled four hours by foot in Nepal, heightens women’s risk of being ostracized by their and then endured an eight-hour bus journey to communities and abused by their intimate partners. deliver her fifth child. From BBC News.
Governments around the world have done far too little to combat the entrenched, chronic abuses of women’s and girls’ human rights that put them at risk of HIV. Misguided HIV/AIDS programs and policies, such as those emphasizing abstinence until marriage, ignore the brutal realities many women and girls face. By failing to enact and effectively enforce laws on domestic violence, marital rape, women’s equal property rights, and sexual abuse of girls, and by tolerating customs and traditions that subordinate women, governments are enabling HIV/AIDS to continue claiming the lives of women and girls.
Domestic Violence
Domestic violence is not only inherently dehumanizing, it is a central cause of women’s HIV exposure. Domestic violence limits women’s capacity to resist sex and to insist on their spouse’s fidelity or condom use. Yet most countries dismally fail to prevent domestic violence, prosecute or otherwise punish perpetrators, or provide health or legal services to survivors. Most do not even recognize its link with HIV/AIDS. Marital rape is rarely treated as a crime.
Human Rights Watch has interviewed woman after woman across Africa and in the Caribbean, many of whom said that domestic violence and spousal rape caused or contributed to their HIV infection. Hadija Namaganda, a Ugandan woman living with HIV, told Human Rights Watch that her husband routinely forced her to have unprotected sex with him and beat her viciously.
The Echo Foundation 42 “One by One by One……..” Himself HIV-positive, he once attacked her so violently that he bit off half of her left ear. When he lay dying of AIDS and was too weak to beat her, he ordered his younger brother to do so. Gabriela López, a twenty-four-year-old Dominican woman with five children, told Human Rights Watch that she became infected with HIV after repeated rapes by her husband. After she tested positive for HIV, her husband abandoned her and their children.
Studies have shown that domestic violence contributes to higher HIV infection rates. A recent South African study found significantly higher rates of HIV infection in women who were physically abused, sexually assaulted, or otherwise mistreated by their intimate male partners.
Abuses of Women’s Property and Inheritance Rights
In some regions, most prominently in sub-Saharan Anti-domestic violence advertisement. From Searcy Africa, women are denied equal property rights. and Searcy Training Services.
• Many widows are barred by law and custom from inheriting property, evicted from their lands and homes by in-laws, and stripped of their possessions. • Divorced women are often expelled from their homes with only the clothes on their backs.
A woman’s access to property usually hinges on her relationship to a man. When the relationship ends, the woman stands a good chance of losing her home, land, livestock, household goods, and other property. While this discrimination stems from customs that favor men for inheritance and property ownership, it is also enabled by government policies and laws that discriminate in inheritance and divorce matters.
In countries like Kenya, where twice as many women are HIV-positive as men, the AIDS epidemic magnifies the devastation of women’s property violations. AIDS deaths expected in the coming years in Africa will result in millions more women becoming widows at younger ages than would otherwise be the case. These women and their children will likely face not only stigma against people affected by HIV/AIDS, but also deprivations caused by property rights violations.
Imelda Orimba, a Kenyan widow with AIDS, told Human Rights Watch that when her husband died, she told her in-laws that she had AIDS and wanted to stay in the house. They grabbed her property anyway. She recalled: “I told my in-laws I’m sick…but they took everything. I had to start over...they took sofa sets, household materials, cows, a goat, and land. I said, ‘Why are you taking these things when you know my condition?’ My in-laws do not believe in AIDS. They said that witchcraft killed my husband.”
The Echo Foundation 43 “One by One by One……..” Children orphaned and affected by HIV/AIDS, especially girls, are also at risk of property- grabbing when their parents are sick or die. A sixteen-year-old orphan girl in Zambia told Human Rights Watch that after her father died, “The relatives grabbed all our property, even my clothes. I didn’t even get a single spoon. This was my father’s relatives.” When her mother died, she ended up living with an uncle who sexually abused her and who is feared to be HIV-positive.
Divorced and separated women fare no better. Many countries have no statutory law on division of family property upon divorce, leaving the matter to the discretion of judges or traditional leaders. Countless divorced women have told Human Rights Watch that they have no hope of prevailing in property rights claims due to the biases against women among judges and traditional authorities. Denying women equal property rights upon divorce also The red ribbon is a symbol of solidarity facilitates domestic violence, again posing the risk of HIV. with HIV/AIDS victims. From the UN. Women in Kenya and Uganda told us that they remained in violent relationships because leaving would mean losing their homes and other material belongings.
Harmful Traditional Practices
Traditional practices of some communities heighten the HIV risk for women and girls. While customs are important to community identities and human rights law supports the preservation of customs and traditions, this cannot be at the expense of women’s and girls’ rights and health. Just as discriminatory statutes must be amended to protect women’s and girls’ rights, harmful traditional practices must be transformed to eliminate abusive aspects.
Human Rights Watch has documented the dangers of a number of traditional practices in the context of HIV/AIDS, including payment of bride price, widow inheritance, and ritual sexual “cleansing.”
The payment of bride price by a man’s family to his future wife’s family is a considerable obstacle for women attempting to leave abusive relationships. Though the intent may be to show appreciation to the bride’s parents and reinforce relations between families, bride price is perceived by many to be an outright purchase of a wife. Masturah Tibegwya, a Ugandan woman, told us, “They take you as property so if the man comes for sex you don’t say no.” A study of several districts in Uganda found that 62 percent of the respondents identified bride price as a major cause of domestic violence, as it encouraged men to beat wives who did not “measure up.” This dynamic also obstructs women’s ability to negotiate safer sex.
In some places, widows are coerced into engaging in risky sexual practices upon the death of their husband. These practices include “widow inheritance” (also known as “wife inheritance”) and ritual sexual “cleansing.” “Widow inheritance” is where a male relative of the dead husband takes over the widow as a wife, sometimes in a polygamous family. “Cleansing” usually involves
The Echo Foundation 44 “One by One by One……..” sex with a social outcast who is paid by the dead husband’s family, supposedly to cleanse the woman of her dead husband’s evil spirits. In both of these practices, safer sex is seldom practiced and sex is often coerced. While some women consent to these practices, others are coerced into them in order to stay in their homes and keep their property. Rejecting these practices can result in social exclusion or rape. Succumbing to them can contribute to HIV infection.
Emily Owino, a Kenyan widow, told us that shortly after her husband died, her in-laws took all her possessions—including farm equipment, livestock, household goods, and clothing. They insisted that she be “cleansed” by having sex with a social outcast as a condition of staying in her home. They paid a herdsman the equivalent of U.S. $6 to have sex with Owino, against her will and without a condom. She told us, “I tried to refuse, but my in-laws said I must be cleansed or they’d beat me and chase me out of my home.” The in-laws eventually forced her out of her home anyway. She and her children were homeless until someone offered her a small, leaky shack. No longer able to afford school fees, her children had to drop out of school.
Sexual Abuse of Girls
In many countries in sub-Saharan Africa, HIV prevalence among girls under age eighteen is four to seven times higher than among boys the same age, and girls have a lower average age of death from AIDS. Sexual abuse contributes directly to this disparity in HIV infection and mortality. Coercion—physical, psychological, and economic—looms large in many girls’ sexual experiences. Yet governments are failing to provide basic protections from sexual abuse that would lessen girls’ vulnerability to AIDS.
Sexual abuse of girls by male family members is frequently kept secret, and law enforcement agencies are often complicit in hiding the abuses. In Zambia, where nearly 17 percent of the population aged fifteen to forty-nine is living with HIV, girls told Human Rights Watch of sexual and other physical abuse at the hands of uncles, The delivery room at a health centre in Baoro, stepfathers, fathers, cousins, and brothers. Orphan Central African Republic. The centre is the only girls dependent on their abusers said they feared health facility for a population of 39,000. From BBC losing support, including for schooling, if they News. revealed the abuse. A twelve-year-old girl told Human Rights Watch, “My uncle used to beat me with electricity wires. Before I went to live with my uncle and auntie, I stayed with my big sister’s mother, and my brother used to take me in the bush. Then he raped me. I was eight or nine. I was scared. He said ‘I’m going to beat you if you ever tell anyone.’”
HIV Information and Services: Insensitivity to Women’s and Girls’ Concerns
HIV prevention, testing, and treatment programs are central to fighting AIDS. Yet insensitivity to the concerns of women and girls in these programs often make the solution part of the problem.
The Echo Foundation 45 “One by One by One……..”
Misguided HIV Policies and Programs
HIV risk is fundamentally linked to abuses of women’s and girls’ rights, yet prevention policies and programs often ignore this link. A prime example of misguided HIV prevention programs are those that emphasize an “ABC” approach (“A” for abstinence, “B” for be faithful, and “C” for condom use) over programs promoting women’s and girls’ rights. ABC programs advocate behavioral changes that do not address the social HIV/AIDS support group members in Zambia earn realities limiting women’s and girls’ sexual income making FACE AIDS [an anti-AIDS NGO autonomy and putting them at risk of HIV. Many working in Rwanda and Zambia] pins. From FACE women and girls cannot “abstain” from being AIDS. brutally raped, cannot stop their husband’s infidelity, and lack the negotiating power within their abusive relationship to insist on condom use. Sules Kiliesa, a Ugandan widow, told Human Rights Watch that her husband “would beat me to the point that he was too ashamed to take me to the doctor. He forced me to have sex with him and beat me if I refused…Even when he was HIV-positive he still wanted sex. He refused to use a condom. He said he cannot eat sweets with the paper [wrapper] on.”
The focus on marriage as a preventive factor in HIV policies (as in “abstinence until marriage” programs) is also misguided. In some countries, married young women have higher HIV prevalence than their unmarried counterparts. A recent study among sexually active young women in Kenya and Zambia found that HIV infection levels were 10 percent higher for married than for sexually active unmarried girls. In rural Uganda, another study found that 88 percent of young women living with HIV were married. Another disturbing study in Zambia found that only 11 percent of women believed they had the right to ask their husbands to use a condom— even if he had proven to be unfaithful and was HIV-positive.
Abusive HIV Testing Practices
Testing for HIV is the first step toward obtaining necessary support and treatment. But if testing is done without respect for women’s human rights it can have devastating consequences.
Women who test positive for HIV are at increased risk for domestic violence and social exclusion. Sadly, many women Human Rights Watch interviewed said that health workers had disclosed the women’s confidential HIV test results without their consent. Moreover, some women described grossly inadequate pre- and post-HIV test counseling, calling into question whether the tests were truly voluntary. In some cases, HIV-positive women had necessary medical procedures denied due to discriminatory attitudes of health care providers.
Rosa Polanco, an HIV-positive Dominican woman, told Human Rights Watch that when she was hospitalized for a liver disease, her doctor disclosed her HIV-positive status to her daughters
The Echo Foundation 46 “One by One by One……..” without her consent. When Polanco’s mother discovered her status, she evicted Polanco from the home she had shared with her parents and children. Having no money and no hope for employment in a country where many employers deny work to people with HIV, Polanco moved to a makeshift wooden shack without sanitation, electricity, or running water in a dangerous, remote informal settlement.
As health care providers around the world rush to embrace provider-initiated rather than patient- initiated HIV testing, more women will have the opportunity to test for HIV. But unless testing protocols adequately address the need to protect women’s rights to informed consent and confidentiality, women will also face dangers in their homes and communities. There is an urgent need for greater clarity on what provider-initiated HIV testing means, and what counseling, confidentiality, and other rights protections must accompany such testing. At a minimum, such measures must ensure that women know their options and are given tools to adequately deal with the consequences of both a negative and a positive test result. Meanwhile, governments must act now to ensure that confidentiality measures are in place and enforced.
Rape Survivors Denied Post-Exposure Prophylaxis
HIV post-exposure prophylaxis (PEP), a short course of treatment with antiretroviral medicines administered after rape, can keep rape from being a death sentence by reducing the risk of HIV infection from an HIV-positive attacker. PEP is the standard of care for rape survivors in wealthy countries. Poorer countries have begun to offer PEP to rape survivors, but not without challenges.
In South Africa, for example, the explosive AIDS epidemic and shocking rates of rape and sexual violence make an effective PEP program critical. Unfortunately, Human Rights Watch found that government inaction and misinformation from high-level officials have undermined the effectiveness of its program to provide rape survivors with PEP. The government’s failure to provide adequate information and training on PEP has left both service providers and rape survivors in the dark. Many rape survivors did not receive PEP services simply because neither they nor police and nurses helping them had any idea that such services existed. Poor women and girls and those living in rural areas were often denied access to PEP altogether.
Inequalities in Access to HIV Treatment
As countries gear up for massively expanded antiretroviral treatment programs, urgent attention is needed to ensure that women and girls will access ARVs equitably. Due to pervasive discrimination, women are less likely than men to have the income or assets needed to pay for antiretroviral therapy. Even where treatment is free, basic costs like diagnostic tests or transportation to the hospital may be out of reach of women. In some families, men determine whether women and girls will be allowed to leave the home and take time away from Tablets of the antiretroviral Viracept. From Pfizer.
The Echo Foundation 47 “One by One by One……..” household duties to visit health centers. When male and female family members are HIV- positive and resources are scarce, evidence in some countries shows that men are the first to receive treatment. If a woman defies a man and seeks treatment anyway, there can be violent consequences.
Many Ugandan women told Human Rights Watch that violence, or the fear of violence, prevents them from freely obtaining HIV/AIDS testing and treatment. Service providers reported that many women came to them secretly, fearing that their husbands would beat them if they sought HIV testing or medical attention. Jane Nabulya, a Ugandan woman, said that she secretly tested for HIV in 1999 when she found out her husband had AIDS. She explained: “I was scared to tell him that I had tested HIV-positive. He used to say that the woman who gives him AIDS, ‘I will chop off her feet.’ I have never told him.”
In Kenya and Uganda, women told Human Rights Watch that they could not reach HIV testing and treatment centers because they had no money to travel or pay for care, were too afraid to ask abusive husbands for funds, or were not allowed to leave the home. Rebecca Samanya told us, “I got counseling after he [her husband] had died. I wanted to go before but I didn’t have the means. I wouldn’t ask him. He would quarrel [fight].” Many widows told us that after they had been denied inheritance and lost everything to property-grabbing in-laws, they had no money to A Bangladeshi sex worker holds AIDS ribbons at the start of an anti-AIDS survive, much less pay for antiretroviral therapy and campaign in Dhaka. An estimated 13,000 other health care. people are infected with HIV in Bangladesh. From BBC News. Conclusion
The disproportionate impact of AIDS on women and girls is no accident. It is the direct result of the pervasive abuses of their human rights. Despite the growing consensus that HIV/AIDS is a women’s rights issue, little has been done to change laws and practices that violate women’s rights, put them at risk of HIV/AIDS, and impede their access to HIV information and services.
Combating the rights abuses that put women and girls at risk of HIV is essential to turning around the AIDS crisis. Concrete policy measures are urgently needed and can have immediate and long-term impact. Governments, with the support of donors and international organizations, must act urgently to stop the abuses of women’s and girls’ rights that fuel the AIDS epidemic and impede society’s response.
The Echo Foundation 48 “One by One by One……..” HIV/AIDS Delivers Heavy Blow to Third World Education
From The Seattle Times Aug. 3, 2004 By César Chelala
The HIV/AIDS pandemic is killing teachers at alarming rates in many developing countries, especially in sub- Saharan Africa, delivering devastating blows to students in those countries, their future job possibilities and quality of life.
These observations are supported by a World Bank study that warns that in some countries AIDS is killing teachers at a faster rate than replacements can be trained. These are important facts to keep in mind when allocating resources for HIV-prevention programs. One of the schools in current use in the Zavala District [of Mozambique]. From the Christian Why are these teachers so susceptible to HIV/AIDS? Children’s Fund. Teachers in rural and impoverished areas in developing countries make more money than the general population. They travel more and are more able to afford illicit unions with infected students and other women they meet. In many of these countries, women are taught to be submissive to men, particularly men in positions of authority. Male teachers can exploit this submissiveness.
As a consequence of the HIV/AIDS pandemic, there is increased teacher absenteeism and loss of educators, inspectors, planners and management personnel. Although these losses are more evident in sub-Saharan African countries, they occur throughout the developing world. The pandemic affects not only the supply of education but the quality and management of education at local, regional and national levels.
In Mozambique, experts predict that AIDS will kill significant numbers of teachers and school administrators and have a severe impact on school enrollment. According to some statistics, almost 30 percent of teachers in South Africa are HIV positive, a higher infection rate than in the general population. In Ivory Coast, every week, six teachers die of AIDS, according to a 1998 government study, and the number has probably gone up since then. In several places, private spending on educational fees and other expenses fell almost by half in households with someone with AIDS.
In Zambia, two teachers die for every one that graduates from training school. A Grade 4 school (smallest school) in Zambia has an average of five teachers. Statistics from Zambia’s ministry of education show that one teacher dies every day from AIDS-related diseases. This is the equivalent of the ministry of education closing down one school per week due to loss of teachers.
According to UNAIDS estimates, the annual per-capita income of half the countries of sub-Saharan Africa is falling by 0.5-1.2 percent and the GDP in the most-affected countries may decline by 8
The Echo Foundation 49 “One by One by One……..” percent by 2010. Because of its economic impact, AIDS is reversing decades of slow improvement in child survival, life expectancy, educational progress and economic growth.
In many cases, teachers themselves are poorly informed or not informed at all regarding HIV/AIDS prevention. In addition, many African men are not only reluctant to use condoms but many women do not want men to use them either, since they feel that by using condoms their spouses or companions are questioning their virtue.
Paradoxically, education itself can be a A school for grades one through five in rural Zambia. Public formidable weapon against AIDS. Several domain picture/Florence Devouard. studies have shown that infection rates are lower among educated women. In the 1990s, HIV infection rates in Zambia fell by almost 50 percent among educated women, while there was almost no decline in those who hadn’t gone to school. In Uganda, infection rates are lower among girls who have attended high school.
The fact that in many countries teachers are dying in great numbers by the infection indicates that new and more effective strategies have to be devised to address this issue. Teachers need to be better educated not only about HIV/AIDS and its transmission, but also on how to become better advocates in the fight against the infection.
It is crucial to introduce life-skills curricula early in primary school, since HIV-prevention activities have been shown to be more effective among youngsters who are not yet sexually active. Among the important components of the life-skills curricula are issues of gender equity, how to develop healthy lifestyles and healthy reproductive attitudes, and an understanding of when and how to protect yourself from the HIV infection. Life skills should be taught in an environment with other HIV- prevention interventions.
It is also critical to empower women when they are young. This can help them deal better with sexual advances by teachers and other men. In several countries, there is the widespread belief that by having sex with young women, men can be cured of AIDS.
Because of both biological and cultural reasons, girls ages 15 to 24 in Africa are several times more likely than boys of the same age to be infected with HIV. In Africa, almost 60 percent of HIV- infected people are female, and among teenagers infected with HIV, more than 75 percent are girls. Sex education, when combined with improved communication skills, often leads to delayed sexual initiation, fewer sexual partners and increased use of condoms.
At the same time, governments have to make provisions to replace the current and estimated future loss of personnel in the education sector. Among those provisions is the need to develop new technologies and alternative and innovative ways of making AIDS education available to children. At stake are not only children’s lives, but also the countries’ future development.
The Echo Foundation 50 “One by One by One……..” Why Girls in Liberia Need to Stay at School
From the Guardian’s International Development Journalism Competition, summer 2008 By Kate Thomas
15-year-old Miranda lowers her eyes every time she passes the village school. “I dropped out three years ago,” the former child soldier says with a sigh. “I would have liked to have become a doctor but school was too expensive. Now I sell doughnuts on the street instead.”
Miranda is one of a generation of Liberian girls who have spent more time at war than at school. Her country had little hope of meeting the Millennium Development Goal of having equal numbers of girls and boys in school by 2005. Three years ago, the war-weary West African nation was emerging from a brutal 14 year civil war that brought it to its knees, destroying 70% of school buildings and hundreds of thousands of lives.
Students carrying three-seat benches Almost five years after the end of the conflict, school enrolment to Tennebu Government School in rates hover around the 50% mark. The gender gap is stark; only Liberia. From UNICEF/Adolphus Scott. 31% of girls, compared to 54% of boys are enrolled in primary education in Liberia. All too often it is girls who are forced to drop out of school to boost family incomes. Miranda is one of the lucky ones. She sells doughnuts. Other girls are forced to sell their bodies.
Charlotte Kaicora, headmistress of a primary school in the coastal capital Monrovia, says only a small number of female students successfully make the transition from primary to secondary education. “When families have economic difficulties, it is usually girls who are forced to drop out of school. Boys are seen as future breadwinners and most parents are prepared to invest more in their education,” she says.
Last year the Liberian government introduced the Free and Compulsory Education Act as an initial step to help meet a Millennium Development Goal to have all primary age children enrolled in school by 2015. Under the new law, all children aged between 5 and 11 are supposed to be able to attend school free of charge.
The reality is somewhat different. The costs of uniforms, stationary and other supplies make education unaffordable for many parents. The cost of kitting out three children in school uniforms is $20—two weeks’ wages for the average Liberian. Despite the new government initiative, some primary schools still ask parents to pay unofficial fees.
Thirteen-year-old Jelila Webbah left school at 11 to help her parents in their traditional restaurant on the outskirts of the sprawling capital Monrovia. Damp, rotting benches skirt the counter and the air is heavy with the sweat of labourers stopping for a chat. “I’d like Jelila to return to school,
The Echo Foundation 51 “One by One by One……..” but the money she brings in for the restaurant pays for school uniforms for my sons,” says Jelila’s mother Sarah.
Female students like Jelila often drop out of school when puberty hits. Only 22% of public schools in Liberia have seats and only one third have functioning pit latrines or flush toilets, making the onset of menstruation and other growing pains hard to deal with at school.
It is one of the reasons why aid organisations working in Liberia are prioritising school infrastructure. Agencies say they are noticing that female attendance rates drop when school bathroom facilities are not working.
“We need to ensure that girls not only enroll in school, but stay in school after age 11 or 12. We’re launching a project to reward the families of girl students with bags of rice and other foodstuffs based on their school attendance rates,” says Steve Miller, project coordinator Market in Liberia. From Wikimedia Commons/Kipp Jones. for visions in action, a relief organisation that is working to make education accessible to all Liberians.
The Liberian ministry for education is keen to halt gender inequality in schools but lacks the resources to do so without the support of donor countries such as the UK and US. “Female education is key in this country. If we can boost the number of girls in school, we will reduce the number of girls working on the street and also the number of premature marriages,” says Hawa Gol Kotchi, Liberia’s deputy education minister.
Liberia has one of the highest maternal morbidity rates in the world, partly due to high rates of teenage pregnancy and lack of supportive medical care. With only 54 Liberian doctors in the entire country, medical treatment for complicated labour—more common in young women and girls—is rarely available.
“If girls are in school rather than working on the street, not only are they far less likely to require medical care for early childbirth, they’re also more likely to be able to train as doctors and ease the burden on our health system. Improving female school enrolment rates is an absolute priority in Liberia,” adds Gol Kotchi.
It may be too late for girls like Miranda to go back to school, but for the next generation of Liberian girls, the hope that they will spend more time in the classroom than on the battlefield is worth clinging to.
The Echo Foundation 52 “One by One by One……..” HIV/AIDS Reduces Children’s Education Chances
From IPS News Agency June 12, 2008 By Miriam Mannak
CAPE TOWN—Children who live in communities with an HIV prevalence rate of 10 percent or more have half a year of schooling less than children in other communities. In this way the negative consequences of HIV/AIDS are felt beyond the families that are directly affected.
These facts were presented at a World Bank conference in South Africa by Robert Greener, senior economic adviser at the Joint United Nations Programme on HIV/AIDS (UNAIDS).
One of millions of orphaned Greener was speaking at the Annual Bank Conference on children. From World Vision. Development Economics (ABCDE), which ended in Cape Town yesterday (Jun 11). The theme for this year was “People, Politics, and Globalisation”. The conference was co-hosted by the South African government’s treasury department.
Greener also said that children who lose one or both parents to HIV/AIDS are less likely to remain in school and complete their education than other children. In the long run, this will have negative effects on African economies.
HIV/AIDS hampers “knowledge and skills transmission from one generation to the next which, over time, results in the loss of human capital. This also has an impact on economic growth. Economies need educated and skilled people,” Greener told the conference. The conference also heard that the prospect of a child remaining in and eventually completing school is much more likely in female-headed households.
“In African households, it is usually the father who decides whether a child goes to school or not. However, it is the mother who decides how long the child will enjoy an education,” explained Natalia Trofimenko of the Kiel Institute for World Economy, a research institution attached to the University of Kiel in Germany. “According to our statistics, children growing up in female- headed households are more likely to stay in and finish school compared to their counterparts who live in male-headed households.” For Trofimenko the education of women and girls is not only important for improving their life opportunities as individuals. “When you educate a girl, you increase the chances of her future children to attend and complete school,” she said.
The Echo Foundation 53 “One by One by One……..” Apart from the good news about female-headed households, HIV/AIDS has a worse effect on girls’ than on boys’ education. Aparnaa Somanathan, a health economist at the World Bank, explained the gendered effect of HIV/AIDS on families.
It is usually the older female sibling that is pulled out of school, especially after the death of the mother. “Younger siblings, especially boys, will remain in school,” according to Somanathan.
Samwel Otieno of Kenya’s agriculture ministry indicated that girls are also more likely to be married off early, which means the end of their school education.
Generally, children who have lost one or both parents as a result of HIV/AIDS are more likely to drop out of or be taken out of school. “Children that have lost their parents to HIV/AIDS have on average one year less of education than non-orphans,” Trofimenko said.
This happens because they either drop out due to the A baby is fed at a home for HIV/AIDS emotional and psychological stress or because they are orphans in Soweto, South Africa. From The needed at home. Associated Press/Denis Farrell. According to Trofimenko, older children have a greater chance of quitting when one of the parents dies or gets sick. “Due to their age, these children are more likely to become the designated person to take over the tasks of the missing or sick parent.”
Another factor causing AIDS orphans to leave school prematurely can be found in the financial constraints that HIV/AIDS causes. “Due to high medical bills and the costs of funerals the remaining parent is less likely to keep the children in school—simply because he or she cannot afford it,” Trofimenko explained.
Children that have lost both parents to HIV/AIDS and are absorbed in extended families also have a smaller chance of finishing school. “Foster parents might have a different idea about the necessity of education than the child’s birth parents,” argued Trofimenko. The foster family’s financial situation also plays a big role in whether or not the foster child is kept in school.
Taking these and other factors into consideration, it is crucial to provide HIV-positive adults with anti-retrovirals (ARVs), says Trofimenko. ARVs are medication that is used to prolong the lives of HIV-positive people. “Postponing the death of parents is crucial,” she says. “When extending the life of the parents, you not only improve the child’s overall quality of life but you also increase his or her chance to complete school. This has a positive impact on a child’s life later on.”
According to figures by the United Nations, the worldwide number of children who lost their parents to HIV/AIDS has increased from 8.5 million in 2000 to 14 million in 2006. About 80 percent of them live in Africa. These figures exclude the millions of children whose parents are terminally ill due to AIDS-related causes.
The Echo Foundation 54 “One by One by One……..” AIDS in Africa: A Quest of Trust
From Nature Oct. 11, 2006 By Natasha Bolognesi
AIDS treatment in South Africa is often a tug-of-war between clinicians and traditional healers. Natasha Bolognesi meets a woman who is uniquely qualified to heal the rift.
For most people in the developed world, the words ‘traditional healer’ conjure up the image of a figure cloaked in beads, animal pelts and an air of impenetrable mystery. Someone, in short, whom Western-ers find difficult to understand or trust, and who has rejected biomedical science in favour of mysticism and magic.
This kind of distrust is problematic anywhere, but especially so in African countries struggling with the HIV epidemic. South Africa, the worst affected, is home to an estimated 5.5 million HIV-positive people, many of whom visit traditional healers, or sangomas as they are known locally. Many sangomas have earned themselves a bad reputation among doctors for not referring their HIV patients to clinics for testing and treatment. For their part, many traditional healers fear that Western medicine Traditional medicine in Ouagadougou, Burkina Faso. From Wikimedia Commons/Ferdinand Reus. will harm their patients. Amid this welter of misunderstanding, there is one sangoma who finds herself in the unique position of being able to understand and relate to both sides of the divide. She is finding ways to reconcile the two and to build bridges of trust between doctors and sangomas. And now, her efforts are enriching and informing a pilot project to improve the health and quality of life of HIV patients in South Africa.
British born and bred, Jo Wreford is a doctor of social anthropology and a research fellow for the AIDS and Society Research Unit at the University of Cape Town. She is also one of a small number of white people in South Africa who have qualified as sangomas, and is known to her sangoma colleagues and clients as Thobeka, which means ‘she who can be trusted because she is grounded’ in the Xhosa language. This training, which involved undertaking a spiritual journey with a sangoma mentor, makes it easier for other healers to trust her as one of their own. Her training in anthropology and Western cultural background reassures doctors that she understands and appreciates scientific method.
The Echo Foundation 55 “One by One by One……..” Different Vision
Wreford wears beads, throws the bones, burns the herb imphepho to invoke the guidance of the ancestors, and experiences visions. She says that unlike many of her colleagues, she is comfortable with reconciling her traditional beliefs with science, arguing that biomedicine can treat the body, while traditional healing can help treat the soul. “Neither cures,” she says. “We must therefore use the best of what both systems have to offer to alleviate the AIDS burden, which is both physical and psychological.”
Wreford wants to see doctors and traditional healers working harmoniously side by side. “Both play vital roles in healing the majority of AIDS-afflicted South Africans,” she says. “ARVs (antiretrovirals) are the only medical intervention available to alleviate the physical effects of AIDS. The traditional healer, in addition to using herbs, also works on the spiritual level, which is an essential part of the African healing process that Western medicine does not address.” But this will be a huge challenge. Del Kahn of the department of surgery at the University of Cape Town explains the obstacles: “Most doctors still A sangoma in his consulting room at Faraday Muti and regard sangomas with suspicion because they Traditional Healers Market in central Johannesburg. From the Mail & Guardian/Sumayya Ismail. don’t have training in treating serious organic disease, and the general feeling is that traditional healers do more harm than good in patients with organic illness.”
Sangomas are just as wary of Western physicians. Phillip Kubukeli, founder and president of the Western Cape Traditional Healers and Herbalists Association based in Cape Town, says that during the apartheid regime in South Africa many sangomas believed that doctors administered poison instead of medicine to black patients in the hope of killing them off. “This fear persists today,” says Kubukeli, “although it is not as prevalent as it was.”
Kubukeli adds that traditional healers strongly believe that physicians are out to get their hands on herbal remedies to sell to drug companies. “Many Western medicines are derived from indigenous plants,” says Kubukeli. “This makes traditional healers very suspicious. For example, when I am trying to bridge the gap between sangomas and doctors, the sangomas will often accuse me of trying to sell their remedies to the physicians.”
Driving a deeper wedge between this mutual medical divide is the South African government’s perception that natural remedies can treat AIDS—a view it vigorously promotes. At the International AIDS Conference in 2000, South African President Thabo Mbeki caused an international uproar when he questioned the link between HIV and AIDS. And at this year’s AIDS Conference in Toronto—where South Africa’s stand, covered in beetroot, garlic and lemons, seemed seriously out of place—the South African health minister Manto Tshabalala-
The Echo Foundation 56 “One by One by One……..” Msimang further discredited her government’s AIDS policy by saying people must have a choice between ARVs and traditional remedies.
“As a result of this persistent denial, even at the highest government levels,” says Monika Esser, a paediatrician at Tygerberg Academic Hospital in Cape Town, “Western medicine of predominantly white origin continues to be met with an element of suspicion by black patients and traditional healers.”
It is here, into the turmoil of the AIDS healing conflict in South Africa, that Wreford hopes to throw a lifeline, in the form of a willingness to share her acceptance of both scientific and traditional beliefs with doctors and sangomas. Her hope is that by trusting Thobeka, the one who can be trusted, they can learn to trust each other.
Wreford qualified and practised as an architect in London before deciding to explore the spiritual aspect of her life more, and use this to help people through spiritual healing in Africa. Before leaving London, she embarked on a course of Jungian psychotherapy, which emphasizes exploring the unconscious through the use of visualization and dreams. Wreford says it helped to prepare her for the intense spiritual demands made on her during her sangoma training.
What Western medicine needs to understand, says Wreford, is that many Africans believe that their ancestors live in a separate realm and carry with them answers to the deep questions about the cause of illness. “This knowledge is accessed by the sangoma through ritual, visions, dreams and herbs, and communicated to the patients, who then feel they have redressed the situation, which prompts more complete healing,” she explains. “Like psychotherapy, it can also help people cope with stigma and emotional strain in the face of a disease such as AIDS.”
Spreading HOPE
Wreford plays an equally vital role in explaining to her sangoma colleagues the importance of biomedicine in fighting AIDS. “Here my role is specific,” she says. “Sangomas believe that the disappearance of symptoms through the administration of a herb means that they have cured the patient of AIDS. I have to explain to them that this is not so and that the application of ARVs, which do not cure either, at least enables the patient to live life Cape Town, South Africa. From National Geographic/Henner Frankenfeld- normally.” PictureNet Africa.
The Echo Foundation 57 “One by One by One……..” But alone, her efforts are a drop in the ocean. According to the Western Cape Traditional Healers and Herbalists Association, there are more than 200,000 sangomas in South Africa—vast numbers spread over a vast country.
So Wreford was invited to join forces with HIV Outreach Programme and Education (HOPE), a non-profit, non-governmental organization based in Cape Town. HOPE is currently running a pilot study in five townships outside Cape Town to build mutual trust and acceptance between sangomas and doctors. It aims to encourage them to collaborate on HIV/AIDS intervention, to avoid disruption of ARV treatment through mistaken herbal administrations and to persuade more male clients to volunteer for HIV testing.
The project operates on a cross-referral system between nine traditional healers and primary- health-care clinics in the townships. The healers, having been taught to recognize the symptoms of HIV infection and the importance of ARVs, refer these patients to a clinic for testing, counselling and treatment. The patients then come back for traditional spiritual counselling from the healer.
HOPE’s recruitment and training of sangomas for the pilot study in October 2005 sparked misgivings at first. According to HOPE training officer Pauline Jooste, one healer said: “We were very scared—the facilitator was a white person.” Now the response seems more positive. Nomsisi Stefans, a practising sangoma from Mfuleni township outside Cape Town, says: “I am happy with HOPE and, if I think they should, my clients are happy to go to the clinic to be tested, especially if I go with them.”
The project is closely monitored and aided by Wreford. She participates in a monthly support and supervision day for all participants, regularly visits the clinics and sangomas to ensure commitment and quality, and lectures medical students and doctors on the need to recognize and respect the value of spiritual healing.
Much help is necessary if the project is to work. Nocawe Frans, a HOPE member and social worker at Tygerberg hospital, points out that many traditional healers are reluctant to spread HOPE’s message because they resent Western interference in African traditional medicine. “It is also difficult for sangomas to refer patients to a hospital because in African culture the hospital A HOPE sangoma workshop. From HOPE. carries a strong association with death—parents often take their children out of hospital and to a sangoma instead,” she says.
Despite these challenges, the five-month-old project is beginning to show a slight increase in patient referrals to clinics from traditional healers, although exact numbers are hard to come by, says Esser, who is also a HOPE management member. Patients tend to go to clinics outside their community owing to the persistence of an enormous AIDS stigma in South Africa.
The Echo Foundation 58 “One by One by One……..” Also encouraging are signals from both camps that Wreford’s and HOPE’s efforts are working. “I think we underestimate the spiritual needs of patients—the ‘healing’ rather than the management of treatment and cure that we are familiar with in Western medicine,” says Helena Rabie, a specialist in HIV/AIDS in children at Tygerberg hospital. “If we can succeed in tapping into the traditional healers’ influence as a resource to fight the spread of HIV, it would be wonderful.”
Confidence is rising among sangomas too, according to Kubukeli. “Thobeka is truly great,” he says. “She has helped my colleagues understand Western medicine. We want to see the HOPE project grow.”
HOPE chairman, Reverend Stefan Hippler, is optimistic that, if the project succeeds, it could inform HIV policy in other African nations as well. “Traditional health practitioners are important role models and leaders in their communities,” he says. “They are indispensable for all national efforts in the fight against HIV and AIDS.”
Natasha Bolognesi is a freelance health writer based in Cape Town.
The Echo Foundation 59 “One by One by One……..” Refugees Denied Access to Health Care
From IPS News Agency July 1, 2008 By Kristin Palitza
DURBAN—Refugees and migrants do not have adequate access to health care services in South Africa, aid organisations and NGOs say. This is particularly detrimental for those who are HIV- positive and in need of continuous antiretroviral (ARV) medication: interrupted treatment can mean illness, development of drug-resistance and ultimately death.
“Displacement carries huge risks for people with chronic illnesses of not being able to access the medication they need,” explains Treatment Action Campaign (TAC) spokesperson Nathan Geffen. “But so far (refugees and migrants) have received poor support from the national Department of Health.”
Adherence is absolutely crucial for those who are on ARVs, and treatment interruption can have serious health implications and ultimately threaten the patient’s life. “Disruption of treatment can cause the viral load to go up and TAC activists at a march on Parliament [Cape Town, CD4 count (which measures the number of T- South Africa] in Feb. 2003. From TAC. helper cells in a person’s body) to go down over a reasonably short period of time,” explains Geffen.
South African NGOs like TAC—a national activist organisation founded by HIV-positive activist Zackie Achmat in 1998, which lobbies for better access to ARV treatment―have recorded cases where HIV-positive immigrants have started ARV treatment in their home countries but were unable to continue with their regimen because they were unlawfully refused treatment in South African clinics.
Since 1998, refugees have the same rights to access health services as South African citizens, but despite this, many are not able to exercise those rights. “By law refugees have access to healthcare services in South Africa, but in reality they are facing difficulties accessing those,” says Office of the United Nations High Commissioner for Refugees (UNHCR) senior regional HIV and public health coordinator Gloria Peutras.
The UNHCR has observed cases where foreign nationals have been refused treatment in clinics by nurses and doctors who are not aware of the law, she explains. “Our staff has reported cases where health workers displayed xenophobic attitudes and preferred to give treatment to South Africans only,” says Peutras.
The Echo Foundation 60 “One by One by One……..” Médécins Sans Frontières (MSF) has made similar observations. “We have noted that refugees have not been given correct treatment at clinics,” says MSF programmes director Jonathan Whittall. “We have witnessed discrimination against treating foreigners versus South African citizens in clinics, and often, MSF personnel will have to accompany refugees to clinics to ensure they are given medical attention.”
Eric, a 33-year-old refugee from Burundi, confirms that xenophobic attitudes are widespread among South African health care personnel: “We are treated with contempt, are made to stand in the back of the queue or ignored. And in the end, many of us are sent home without any medication.”
Immigrants find themselves pushed to the back of a line that is also failing South African citizens. According to TAC, about half a million HIV-positive South Africans—who with a CD4 count below 200 qualify for treatment—are currently on the Migrants are at elevated risk for HIV/AIDS and other diseases, yet waiting list; South Africa’s health department insists the routinely denied treatment. From number was much lower, at about 30,000 patients. IPS News Agency/Kristin Palitza.
Refugees who feel discriminated against or who lack documentation, transportation and financial resources may decide not to seek healthcare services even though they are in need of medical attention.
“Out of fear of deportation, many refugees and illegal immigrants are in hiding and choose not to seek healthcare. Even those with legal refugee status remain afraid (of the South African authorities),” says Whittall.
MSF therefore brings health services to migrants, rather than expecting migrants to come to them. The organisation provides mobile, primary healthcare to refugees and migrants in camps and other shelters. It also offers to treat illegal immigrants anonymously so that they can seek help without fear of being deported.
What makes the health situation of refugees and migrants worse is that they often have to survive in inadequate living conditions—like overcrowding, poor nutrition, insufficient ventilation, lack of sanitation and little access to clean water—that pose health risks and expose them to diseases such as tuberculosis, which has a particularly negative impact on the health of a HIV-positive person.
“Currently in South Africa, refugees’ constitutional rights to health care, food and shelter are compromised. Thousands live crowded together with very little space,” says Geffen. Such conditions pose a “huge health threat” and make it difficult to contain epidemic outbreaks, he told IPS. “The risk of tuberculosis and other infectious diseases is acute.”
The Echo Foundation 61 “One by One by One……..” Another difficulty is that refugees have generally had little exposure to information on HIV and AIDS both in their home countries and in South Africa—as a result of illiteracy, lack of access to information and language barriers.
“There is no targeted information on HIV and AIDS in multiple languages available in South Africa,” says Whittall. “Lack of access to condoms further exposes migrants to HIV infection.”
Moreover, conflict disrupts educational systems and social programmes, robbing children and adults of opportunities for HIV education. “People in conflict settings are often isolated and don’t have the level of awareness [about HIV] that you see in non-conflict-affected populations,” notes Susan Purdin, senior technical adviser for reproductive health at the International Rescue Committee (IRC) in the 2008 World Disaster Report, which was released last week by the At the Central Methodist Church in Johannesburg, International Federation of Red Cross and Red hundreds of Zimbabwean refugees gather each evening for prayer. From EVE/Benedicte Kurzen. Crescent Societies.
This lack of knowledge puts populations at particular risk when fleeing from areas of low to high HIV prevalence countries, such as South Africa.
Displacement also increases vulnerability to HIV because refugees and migrants, especially women and girls, are exposed to rape, sexual violence and abuse. Loss of livelihoods may lead some to engage in higher-risk sexual activities, including sex work, the report further states.
MSF has noted a number of cases where female refugees were ambushed and raped immediately after crossing the border between Zimbabwe and South Africa in the last few months.
“We came across a young girl who was raped after crossing the border in Musina, for example. She went to the local clinic after the rape but was sent away. MSF found her five days later, but by then it was too late to provide her with post-exposure prophylaxis,” says Whittall. Post- exposure prophylaxis decreases the risk of HIV infection if administered within 72 hours after the exposure to the virus.
Aid organisations expect the South African government to swiftly put strategies into place that assist refugees and migrants to access health care services. “The first step government needs to take is making sure that all refugees get legal status and stop deportation so that they can fearlessly seek help,” says Whittall.
“We also need standardised treatment protocols within the entire Southern African Development Community region so that there are comprehensive guidelines on treatment of refugees that fit within the South African national treatment plan,” he further explains.
The Echo Foundation 62 “One by One by One……..” Brain Drain Hits Poor Countries Hard
From IPS News Agency Mar. 23, 2006 By Gustavo Capdevila
Kenya is just one of many developing countries worried about the growing loss of healthcare workers, who mainly migrate to industrialised nations, said Dr. Francis Kimani of Kenya.
Most of Africa faces the same problem, which has led to an estimated shortage of around 820,000 doctors, nurses and other health workers throughout the continent.
Although the total shortage of health professionals worldwide is estimated at around four million, most of the demand is concentrated in industrialised countries, due to largely demographic reasons.
The majority of the migrating health workers come from the world’s least developed countries, especially in Africa and Asia, where health professionals typically earn low wages and have little prospect for advancement in their careers, Kimani told IPS.
Other reasons for emigrating are a poor working environment and lack of motivation, said Kimani, director of Medical Services in Kenya’s Ministry of Health.
Isaac Ziba, a nurse who left Malawi with his family in 2004 to work in the Western General Hospital’s surgery department in Scotland’s National Health Service, said his decision was motivated by several of these concerns, notably “career advancement, further training, new experiences, and better remuneration.” From the Center for American Progress.
“I made a good decision for myself and possibly my family,” he told IPS. When asked whether he planned to return to his country eventually, he said he was not sure.
In the case of Africa, the phenomenon takes on unique dimensions because the “brain drain” has coincided with the HIV/AIDS epidemic. Africa has accounted for the majority of the 25 million people killed so far by the disease worldwide.
The Echo Foundation 63 “One by One by One……..” But despite its disproportionate burden of HIV/AIDS and other contagious diseases, Africa only has 0.6 percent of the world’s registered healthcare professionals.
The other side of the coin is seen in industrialised countries, which have ageing populations and declining birth rates, making it difficult to replace retiring health workers, and creating a large proportion of people with special healthcare needs.
This is illustrated by two of the countries with the “oldest” populations, Japan and Italy. By 2050, Japan will have 77 pensioners for every 100 workers, compared to 30 for every 100 in 2005. And in Italy, the ratio will have risen from 30 per 100 to 75 per 100.
By contrast, the developing countries have reduced infant mortality in recent years, and while fertility rates are slowly declining, the future is expected to bring an explosive increase in the number of young people entering the labour market.
These are just a few of the considerations being addressed by the experts gathered together by the International Organisation for Migration (IOM) for a seminar on Migration and Human Resources for Health, taking place Mar. 23-24 in Geneva.
Danielle Grondin, director of the IOM Migration Health Department, began by stressing that the migration of healthcare workers is not a new phenomenon. As far back as the early 1970s, there were already more Filipino nurses working in Canada and the United States than in the Philippines, she noted. “Now it is an issue because of increased growth in the scale of the flow,” she explained.
There is a greater demand for health care personnel in many developed countries due to population ageing, which has started to create special health needs at the same time that the overall population is shrinking, she said.
“But there are also considerable concerns about the economic, social and health situation in the poorest countries,” she added.
Grondin also emphasised that migration of health workers is a global phenomenon, and is no longer “just a South-North issue.” Today migration can be North-North, as with Spanish nurses recruited in France; South-South, with doctors heading to South Africa from neighbouring countries like Kenya; or East-West, as large numbers of Polish nurses emigrate to the U.K., she explained.
Moreover, the loss of health professionals is not solely due to the international mobility of health professionals, but also to internal migration, because in many countries—both developed and developing—health workers move from rural to urban areas. “This internal migration compounds the drain brain effect of international migration and contributes to inequities in access to healthcare within countries,” said Grondin. “Another type of loss associated with migration is what we call brain waste, which is associated with the cross-industry migration of qualified healthcare professionals who leave to work in non-health-related occupations,” she added.
The Echo Foundation 64 “One by One by One……..” This “brain waste” is frequently the result of stringent licensing regulations in many of the developed countries, she noted, which means that migrant health professionals in countries like Canada and the U.K. are unable to put their skills to use by exercising their professions.
In the meantime, there has also been a growing movement of patients to foreign countries for diagnosis and treatment, driven by differences in cost, the availability of quality specialised treatment, and the absence of waiting lists. This movement is facilitated by the increased portability of health insurance and by linguistic, cultural and geographic proximity, as in the case of patients from Bangladesh going to Thailand for treatment, said Grondin.
As a means of curbing the brain drain represented by the flow of health professionals from the developing to the developed countries, some experts recommend improving remuneration and working conditions in their countries of origin. As far as Kimani is concerned, however, this supposed solution is “paradoxical.”
“When you take the most important resources from a poor country, you destabilise the poor country and make it very difficult to improve conditions, because to improve conditions you also require the brains which have left that country. That makes it difficult to improve the reasons or the causes of migration, and it becomes a vicious circle,” he maintained.
A potential solution would be for the developed countries that benefit from the migration of health professionals to compensate the developing countries with the funds and resources that were used to educate them, suggested Kimani.
He also proposed that health professionals who have been recruited from developed countries could remit money back to their country of origin as a form of tax that could be used to finance development programmes.
“When one is educated by taxpayers’ money and then disappears from his country, he no longer pays tax, and therefore he no longer contributes to the welfare of the rest of the society,” he said.
For his part, however, Ziba opposed this strategy, because it would entail double taxation.
In the meantime, there seem to be few prospects for alleviating the growing problem of health workers from the South migrating towards the industrialised nations.
The United States Department of Labour has acknowledged that the country is currently facing a shortage of 125,000 nurses, and this figure could rise to as high as a million in ten years.
And Canada has predicted that its shortage of nurses will reach 195,000 in the year 2011 and 282,500 in 2016.
The Echo Foundation 65 “One by One by One……..” Millennium Development Goals (MDGs) Are “Just Words” If Financing Is Not Made Available
From IPS News Agency June 23, 2007 By Christi Van Der Westhuizen
Development plans like the United Nations Millennium Development Goals (MDGs) are “just words” if financing is not made available to implement the plans, says Jeffrey Sachs, Nobel Prize winning economist and head of the Earth Institute at New York’s Columbia University.
IPS spoke to Sachs at the Local Governments’ International Mid-Term Evaluation Conference on the U.N. Millennium Development Goals which ended in Rome Saturday. He told conference delegates that developed countries’ financing of the MDGs is “totally inadequate”.
“Don’t believe them when they say there is no money. There is more wealth than ever before. The money is just not getting channeled to people who are so poor that they are dying. There is no shortage of A Liberian girl is well prepared to weather a brief, sunny shower on the road outside Monrovia. Lack of basic money in the world. There has been a infrastructure plagues much of Africa. From the National shortage of follow-through from rich Geographic/Spencer Platt-Getty Images. countries.”
He said that donors need to be helped to understand that the MDGs “are not just nice ideas” but that they can be reached with specific interventions. Researchers have spent years developing strategies to achieve the MDG on child mortality, for example. “But now interventions are not done in a systematic way. That is where the break is.”
Sachs is critical of the lack of donor accountability. The MDGs are very specific and require specific interventions, he said. But these interventions are not being implemented because there is no public accountability. “Jobs do not depend on the achievement of the targets so there is no sense of urgency (on the side of developed countries),” said Sachs. “If anything goes wrong, Africa is blamed. And then the response is to build capacity.”
But, the large sums of donor money currently being spent on “capacity building” are wasted if money is not also spent on creating the conditions for such capacity to be utilised, Sachs added.
The Echo Foundation 66 “One by One by One……..” Much more resources are needed to improve healthcare services, sanitation, electricity supply and infrastructure in developing countries.
The capacity of people to improve basic services and infrastructure will be built in the context of carrying out such processes, Sachs argued. He cited agricultural processing as an example, saying that the physical investment first needs to happen before training is done.
Capacity building remains theoretical if it is not part of a physical plan. He is convinced that donors have over-emphasised capacity building as a goal in itself. “It is everybody’s favourite. But it is a lazy way of thinking,” said Sachs. “Too much money is spent on meetings, conferences and workshops that lead nowhere.”
Money should be spent on concrete actions, instead. Development starts with money, he said. First the financial resources should be made available; then systems should be put in place, paid for with those financial resources. The result would be “real paved roads, real electricity, real infrastructure”.
Without financing, “everything becomes hypothetical. I am trying to get us to move from words to action”.
Sachs regards the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Millennium Villages as successful examples of financing development. The latter refers to a project of Sachs’ Earth Institute where experts have been working with the residents of villages in Tanzania and Kenya to address their developmental challenges in a systematic and practical way. Jeffrey Sachs explains the vitality of the United Nations “Millenium Project” plan to take on He said that without the improvement of infrastructure poverty. From The Michigan Daily/Mike in African countries, investors are unlikely to be Hulsebus. interested in doing business in such countries. Cities need basic infrastructure and a basic level of management to create a cycle of investment, export promotion, increased city revenues and job creation.
As the cycle becomes entrenched, cities become better at building markets, trade and production. This is the way in which a city becomes globally competitive, Sachs said.
Sachs supports the direct funding of cities rather than working through national governments. “Not everything has to go through national treasuries. You can skip one or two steps and go directly to local government level. In this way you cut transaction costs.”
This does not mean excluding national governments, he said. They should agree to the direct funding of local governments. Examples of this way of working are the Millennium Villages where the money is spent at local level with the buy-in of heads of state.
The Echo Foundation 67 “One by One by One……..” Why Aid Does Work
From BBC News Sept. 11, 2005 By Jeffrey Sachs
Aid Works, When It Is Practical, Targeted, Science-Based and Measurable.
Hence, we have seen the successes of immunisation campaigns for children in impoverished countries, against diseases such as polio, diphtheria, and measles.
These clear aid triumphs have saved the lives of millions of children. Similar aid-backed successes have been achieved in the fight against African river blindness, trachoma, leprosy, and guinea worm.
To make these successes sustainable, however, the aid in an area like health needs to be complemented by practical and targeted aid in other areas like schooling, safe drinking water, and especially agriculture. Shoots of Growth
Perhaps the key to Asia’s economic takeoff in the past 30 years was the successful Green Revolution of India, China, and much of southeast Asia.
When Asian farmers could grow more food, feed their families and communities, and diversify into cash crops and into non- agricultural activities, the economic takeoff could get underway.
Green Revolution crops increased The Green Revolution itself was heavily spurred by timely and rice yields in Asia. From BBC News. targeted aid from the Rockefeller Foundation, the US government, and other donors. Undeserved Bad Press
Aid has received a bad press in recent years, but for utterly the wrong reasons. Current aid flows suffer from four inter-related flaws: • The aid is too little to solve the problems at hand. • The aid is excessively directed towards the salaries of consultants from donor countries rather than investments in recipient countries. • The aid is not well spread across sectors, with a particular neglect of agriculture in recent years. • The aid is not properly coordinated among the donors themselves, leading to a plethora of disconnected projects, rather than a true national strategy.
The Echo Foundation 68 “One by One by One……..” The greatest need for more and better aid is in Africa. If the donors would help Africa to fight disease and to achieve a Green Revolution as occurred in Asia, we could get past these seemingly endless debates by enabling Africa finally to escape from the trap of extreme poverty.
Ironically, when under-financed and flawed aid programs have fallen short, public opinion in some quarters has turned against aid itself rather than in favour of more and better aid.
The US government and its allies have tended to blame the poor for these “aid failures,” making an unfair blanket charge of “corruption,” rather than acknowledging truthfully the shortcomings of the donor efforts themselves. Atlantic Divisions
Europe has recently realised the need for more and better aid, pledging to increase donations to 0.7% of EU GNP by 2015.
The Bush administration by contrast is still battling against increased aid flows.
America’s lack of adequate aid funding, alas, continues to imperil not only the poorest countries but also global stability itself, and therefore the very national security of the US.
The UN World Summit offers a critical opportunity to get the aid strategy back on track.
All donor countries, including the US, have committed to making concrete efforts towards the target of 0.7% of GNP in aid, but the US, unlike Europe, has not followed through.
All of the world’s governments have committed to supporting the Millennium Development Goals, but the Bush administration is now attacking those shared international goals because of its aversion to the increased aid needed to achieve them.
One big test of the forthcoming summit, therefore, is whether the US government will stick stubbornly with its overwhelmingly military approach to global security—an approach that is palpably failing—or whether it will finally wake up to the realisation that by helping the poorest of the poor, it could also help the richest of the rich to benefit from a safer and more prosperous world.
Jeffrey D. Sachs is the Director of the Earth Institute at Columbia University and author of The End of Poverty (Penguin, 2005).
The Echo Foundation 69 “One by One by One……..” Why Aid Doesn’t Work
From BBC News Sept. 11, 2005 By Fredrick Erixon
Sound economic policies, not aid, have lifted millions of Asians out of poverty. -Fredrik Erixon
The aid sector is booming. In the last three years, foreign aid has risen by one third and today stands at US$78.6 bn. In 2010, government spending on aid is projected to be above US$125 bn a year.
What are we to expect from this new wave of aid spending? Will it, once and for all, lift people out of poverty or will it most likely achieve very little—perhaps even be counterproductive?
These are the core issues. Hardly anyone opposes the idea that first-world countries should assist developing countries, if that assistance helps countries to develop. The question is: does it?
I am afraid it does not.
Failure of the Big Push
The new ‘big push’ of development aid has been tried many times before but always with dismal results. The call for redoubling aid to eradicate poverty has been responded to many times over, but it has never delivered what it promised.
In spite of more than US$1 trillion in aid to Africa over the last 50 years, the big push in development has yet to occur.
Between 1970 and 1995 aid to Africa increased rapidly and aid dependency (measured as the aid-to-GDP ratio) stood at nearly As African aid rose, growth slowed. 20% in the early 1990s. Measured differently, the mean value World Development Indicators of aid as a share of government expenditures in African Online. From BBC News. countries was well above 50% between 1975 and 1995.
During the same period, GDP per capita growth in Africa decreased and was for many years even measured in negative figures. The unfortunate fact is that most African countries are poorer today then they were at the time of their independence from colonial powers.
The Echo Foundation 70 “One by One by One……..” If the idea of aid had been true—in particular the alleged link between aid, investment, and growth—many of those countries would today have eradicated extreme poverty and have a GDP per capita similar to that of New Zealand, Spain or Portugal.
If nothing else, aid to Africa seems to have lowered rather than increased economic growth.
Corruption and Bad Decisions
Why has aid failed to deliver higher economic growth for developing countries? Partly because aid has not been spent in the way it was intended. Instead of gearing up investments, money was spent on current spending and public consumption—which, in turn, led to a rapidly growing public sector in the economy.
Needless to say, this strengthened other socialist tendencies in the economy and investment became, in many developing countries, mainly a government activity.
In addition, aid boosted fiscal budgets and led to a rapidly growing number of parastatals and state-owned enterprises. Largely supported by the donor community at the time, these soon became arenas of corruption and this corruption spread like wildfire to other parts of the society. Mozambique and other African countries adopted Socialist policies. The tragedy of aid, as been shown in numerous evaluations and From BBC News. by World Bank research, is that donors are part of the problem of corruption; aid often underpins corruption, and higher aid levels tend to erode the governance structure of poor countries.
In other words, donors have failed to follow the chief principle of the Hippocratic oath: do no harm!
However, the major reason for the low effect of aid has been policies detrimental to economic growth in the recipient countries.
Closed African Doors
It is sound economic policies, not aid, that in the last decades have lifted millions—even billions—of Asians out of extreme poverty, and provided the resources to limit the extent of (or in some countries, eradicate) starvation, diseases, and other visible signs of poverty.
Inversely, it is bad economic policies that still keep millions of Africans in deadly poverty.
When several Asian countries started to open up for trade and foreign direct investment, the policies that created the ‘Asian Tigers’ and the ‘Asian Miracles’, many African countries headed for a model of economic autarky, closed the borders, and regulated the domestic economy to absurd degrees.
The Echo Foundation 71 “One by One by One……..” It is hardly surprising that this strategy of development has failed bitterly.
What is more, donors supported these policies. And many donors are still pouring money into countries with policies detrimental to growth.
Instead of focusing on the quality of aid and how to raise the output through a more productive use of aid, donor countries and others are solely occupied by increasing the quantity of aid.
Regrettably, caution is therefore warranted. Aid to countries that are not performing well tends to strengthen the factors of under-development, and increased aid to countries that have entered the economic reform route runs the risk of derailing the reform process.
Trade in the Aid
The question then is not if rich countries can afford to give more aid to developing countries. It is obvious that they can.
The question is whether this aid can reduce poverty by promoting economic growth.
Sadly, the history of aid does not show that it can. Nor does it seem that world leaders, not to mention Bob Geldof and other campaigners, have any real idea how the aid given can be made Do Bono and Sir Bob know how the more effective. extra aid should be spent? From BBC News. So, here is what donor countries should do.
• do not spend any more money on development aid • withdraw all aid to countries that are not pursing sound economic policies and that fail seriously to build institutions for democracy and transparency • countries that meet these high standards should, within a limited period of time, be assisted with ‘locking-in’ already accomplished reforms and, in particular, with pursuing additional reforms • rich countries should immediately open up their markets for exports from poor countries
Trade has proven to be instrumental to poor countries development. Aid has not.
Fredrik Erixon is the chief economist of Timbro, a Swedish think-tank, and author of Aid and Development: Will it Work this Time? (International Policy Network, 2005).
The Echo Foundation 72 “One by One by One……..” Inside Zimbabwe’s Healthcare Crisis
From The Christian Science Monitor May 30, 2008 By Scott Baldauf A journalist who cannot be named for security reasons contributed from Harare, Zimbabwe.
Lucia Munenzwa was shell-shocked when she was presented with a list of items that the local clinic needed for her to give birth at the health center. Top of the list were 10 pairs of latex gloves to be used by the midwives. There were also a surgical blade, clamp cord, cotton wool, linen saver, and rehydration fluid. To buy all the requirements, Ms. Munenzwa, a young widow who survives by selling items on the street, needed about $20 billion Zimbabwean dollars (nearly US $40)—a figure well beyond the reach of any ordinary Zimbabwean.
“The nurses have just told me that without the items, they can’t allow me to give birth here,” she said with tears in her eyes as she walked out of the clinic, heading home. Two days later, Munenzwa gave birth at home, with the assistance of an Robert Mugabe, President of elderly neighbor. She named her baby boy Lucky. Zimbabwe. Public domain picture/Jeremy Lock-USAF. The collapse of Zimbabwe’s health sector, once the envy of many African countries, may seem to be an internal matter— yet another sign of the country’s economic woes. But the flood of an estimated 3 million Zimbabwean refugees from their country—fleeing as much for food and medical care as for political freedom—has quickly spread Zimbabwe’s internal crisis to other countries. The ongoing anti-immigrant violence in South Africa shows that Zimbabwe’s problems have regional repercussions, putting pressure on African leaders to come up with solutions…fast.
“What this shows is that effectively there is no government in Zimbabwe,” says Chris Maroleng, a Zimbabwe expert at the Institute for Security Studies in Tshwane, as Pretoria is now called. “It says to us that in the end, we must have this issue of human security as an essential starting point for solving the crisis. But the question is how to get to the starting point. The international community that normally intervenes in situations like this is unwelcome now in Zimbabwe. So unless we resolve the underlying political problem, we’re going nowhere.”
Signs of the healthcare crisis have been obvious for some time to the few doctors still available in the country’s largest hospitals, Parirenyatwa and Harare General Hospital.
At Parirenyatwa Hospital, only 1 out of 18 dialysis machines works. At Harare General, only 3 out of 50 incubators works, and the neonatal unit is seriously understaffed as nurses and doctors leave for more stable jobs abroad. There is only one radiologist who is servicing Harare and Parirenyatwa hospitals and the Zimbabwe National Army (ZNA). That radiologist is “borrowed” from the Army. Refrigerators in the mortuary area at Harare General have stopped working. Two weeks ago, surgeons and anesthesiologists at Parirenyatwa stopped doing any operations to protest the poor working conditions and inadequate supplies. The surgeons say they are afraid of
The Echo Foundation 73 “One by One by One……..” ruining their reputations by continuing to lose patients by going into theater without adequate supplies.
Douglas Gwatidzo, chairman of the Zimbabwe Association of Doctors for Human Rights, describes the situation in Harare’s health centers as “dire.” “About one doctor is serving over 8,000 people in the country, [compared with] the world standard of 1 doctor to 500 patients,” says Mr. Gwatidzo. “It’s quite sad.”
Many mothers walk into Harare Central Hospital’s neonatal unit with little hope of taking their infant children home alive. “I tell you those who come out alive only do so by the grace of God,” says Mary Moyo, a young mother who had her child hospitalized in the unit last week.
In Zimbabwe’s second-largest city, Bulawayo, AIDS patients come to Thembelihle House for their last hope of a dignified end. Thembelihle is a hospice designed to provide terminally ill AIDS patients with enough food for them to regain their strength so their families can look after them.
But the shortage of drugs and medical supplies, the rising cost of food, and the growing poverty of An unidentified patient is lifted from an ambulance at Zimbabwean citizens are making it a lot harder Parerenyatwa Hospital in Harare, Zimbabwe, Friday, for Thembelihle to do its job properly, says Jan. 12, 2007. From the AP. Gladys Dube, manager of the hospice. She walks through the wards, where 62 of the 70 beds remain empty because of staff shortages. Women wash soiled sheets by hand. Used rubber gloves hang out on clothes lines to dry.
“We have nothing right now,” says Ms. Dube. “We have a few candles in storage, for when the power goes out. Soap at the moment is difficult to find, so we are resorting to an entrepreneur who makes it himself, but the quality is not good.”
She takes the hand of an emaciated young patient who has just checked in, and pats her forehead. “Some come to us in a very bad state. We can improve their nutrition so that they can go home to be looked after by their families.” Aid agencies used to bring food, but there has been no food delivered here in the last month.
While doctors and even members of parliament blame the government for the crisis—Blessing Chebundo, chair of the parliamentary committee on health and child welfare, says the government lacks political commitment—the government itself says it is doing everything in its power to address the health care crisis.
“We are aware of the challenges in the health sector and we are doing everything within our means to tackle them,” says David Parirenyatwa, the minister of health and child welfare. Parirenyatwa Hospital was named after his father, the country’s first black doctor. Minister Parirenyatwa blames the current crisis on economic sanctions against Zimbabwe, placed by Britain and the United States for Zimbabwe’s alleged human rights violations. With little foreign currency, Zimbabwe cannot purchase drugs on the global market. “The shortage of foreign currency is a major impediment,” he says.
The Echo Foundation 74 “One by One by One……..” Nigeria Puts Polio Eradication at Risk
From Voice of America News May 26, 2008 By Lisa Schlein
Health Experts are concerned that a big outbreak of polio in Nigeria this year could put the World Health Organization’s efforts to wipe out this crippling disease at risk. WHO has made enormous progress since it launched its global eradication campaign in 1988. At that time, 350,000 children a year became paralyzed because of polio. That number now stands at 450. Most of the world now is polio-free. But, that achievement is being threatened by reluctance on the part of some religious, traditional and political leaders in the northern part of Nigeria to immunize all their children against polio. Lisa Schlein reports for VOA from Geneva.
At this year’s World Health Assembly, the Director-General of the World Health Organization, Margaret Chan, expressed concern that success in eradicating polio could slip away.
“In Asia, type-1 polio—the most dangerous strain of the virus—is today on the verge of elimination,” Chan said. “But just as we are seeing record lows in Asia, Africa is witnessing a dramatic upsurge of this strain in the northern states of Nigeria, while previously Female health official tries to polio-free countries on the continent are still struggling, struggling drop polio vaccine into mouth of to stop viruses that were re-introduced more than two years ago.” child in Kaiama town. In 2003, northern Nigeria stopped immunizing its children against polio. Hard-line Nigerian clerics called for the boycott. They accused Western countries, led by the United States, of contaminating the polio vaccine to render Muslims infertile or infect them with the AIDS virus.
As a consequence, the polio virus spread from Nigeria and reinfected 23 polio-free countries around the world, including nations as far away as Indonesia and Yemen, causing nearly 1500 children to be paralyzed for life.
The Director of the Polio Eradication Initiative at WHO, Doctor Bruce Ayleward, tells VOA the biggest problem in northern Nigeria is that most parents do not get the chance to choose if their children will be vaccinated. He says data show that less than four percent of the population is saying no to vaccination because of concerns about safety.
“So that massive community resistance due to un-reconciled concerns about the vaccine has been largely addressed,” Ayleward said. “And, we need the full engagement of the traditional, and political and religious leadership to get all parents convinced now that there is no problem with the vaccine. More importantly [is] that they have to protect their children in the face of an epidemic that they are experiencing right now.”
The Echo Foundation 75 “One by One by One……..” Nigeria has had an outbreak of nearly 190 cases of polio this year. The number is a stark contrast to the 16 new cases in India, Pakistan and Afghanistan, the three other polio endemic countries.
Doctor Ayleward says these three countries have done an excellent job in eradicating type-1 polio, the most virulent form of the disease.
“Asia is on track to stop polio and Africa could be rapidly back on track if the right things are done in northern Nigeria by the governors of the key states in the north and the people working for them as they have pledged to do,” he said.
Nigeria’s Minister of Health, Hassan Lawal, says the Nigerian government is working to solve the problem.
“The Federal Government of Nigeria has planned a number of strategies. First and foremost, social mobilization by disseminating information and campaigns to go to people about immunization. It is very aggressively being done,” he said.
Doctor Lawal says the government is making sure that routine immunization is emphasized U.S. President Franklin Delano Roosevelt in a and institutionalized. wheelchair after having been stricken with polio. Public domain picture.
“And, we are trying to go down to those affected areas and speak in their own language, appeal to the traditional rulers, appeal to the religious leaders,” he said. “In other words, I want to assure you so much is being done. The government is responsive and responsible and we want to assure you in no time, polio will be history in Nigeria.”
Doctor Ayleward says he believes polio could be eradicated quickly in Nigeria, once the government devises a way to administer the polio vaccine to every child who needs it.
He also warns that the failure by any nation to fully implement eradication strategies could lead to the failure of the global initiative to defeat polio and spark a re-emergence of the disease.
“It will come rushing back as we have seen in the last few years into places that stopped campaigns,” Dr. Ayleward said. “And, we will not be able to mobilize the resources again to conduct the massive campaigns needed to properly control and keep polio at extremely low, low levels. That is why we have to finish the job of eradication.”
If all goes according to plan, Doctor Ayleward believes Asia will have eradicated polio in the coming 12 to 18 months. He says if Nigeria speeds up its immunization campaigns, polio in Africa could become history shortly thereafter.
The Echo Foundation 76 “One by One by One……..” UK Alleges Misuse of Aid Given for Polio Vaccine
From the Dawn June 30, 2008 By Baqir Sajjad Syed
ISLAMABAD, June 29: Britain has protested over what it calls misuse by the finance ministry of the £15 million assistance for procuring polio vaccine, according to sources in the British High Commission.
The issue is likely to affect another £280 million British aid Pakistan expects to get under the National Health Facility Part-II for the next three years.
British Secretary of State for International Development Douglas Alexander, the sources claimed, would raise this issue with Prime Minister Syed Yousuf Raza Gillani, during a meeting with him here on Thursday.
Britain’s Department of International Development had provided the assistance in response to Pakistan’s request to international donors in February.
Pakistan had told donors that it had run out of funds for purchasing vaccines and the situation had become so grave that there was a serious threat of discontinuation of the polio campaign across the country.
The country needs 100 million doses a year to vaccinate 35 million children. This year, because of resource constraints, the government bought only 20 million doses and the health ministry had to turn to donors for the remaining 80 million doses.
Britain responded to the emergency request and provided the aid with conditions that it should be used only for polio vaccine procurement and the entire amount should be spent by June 30.
The Planning Commission directed the health ministry to purchase the vaccine and asked the finance ministry to release the amount to the health ministry.
After buying the vaccine, the health ministry approached the finance ministry, but it was told that the funds had been used for the ‘balance of budget’.
Shocked to learn that its assistance had been misused, the British Department for International Development wrote a letter to Finance Secretary Farrukh Qayyum, asking him to ensure that the amount was used for the intended purpose.
“The amount (£15 million) was transferred to the government of Pakistan in March 2008 on the understanding that these funds would be used in the FY 2007-08.
The Echo Foundation 77 “One by One by One……..” “The Ministry of Health has completed the vaccine procurement process and polio vaccine is now available for National Immunisation days. However, we are surprised that no funds have been released to the Ministry of Health for payment to the vaccine suppliers to date,” the letter said.
The letter further stated: “We are concerned that this delay in payment could impact negatively on future vaccine procurement, and that postponement of payment until July could reduce the funds available for vaccine purchase in the next financial year.”
The Economic Affairs Division, which coordinates all international funding, has also urged the finance ministry to promptly address the issue.
Pakistan’s fight against the crippling disease is already faltering primarily because of poor governance and lack of accountability and 15 polio cases have already been reported ahead of the peak transmission season during the later part of the year.
Some see Pakistan to be lagging behind even the war-torn Afghanistan that has reported fewer cases so far this year.
The Echo Foundation 78 “One by One by One……..” U.N. Confronts Another Sex Scandal
From the Los Angeles Times Dec. 15, 2007 By Carol Williams
Girls as young as 13 were having sex with U.N. peacekeepers for as little as $1.
Five young Haitian women who followed soldiers back to Sri Lanka were forced into brothels or polygamous households. They have been rescued and brought home to warn others of the dangers of foreign liaisons.
The young mother of a peacekeeper’s child had to send the toddler to live with relatives in the countryside after other children and parents U.S. Marines patrol the streets of Port-au-Prince in March 2004 to prepare for a multinational U.N. taunted him with the nickname “Little mission. Public domain picture/Andy Dunaway-USAF. Minustah,” the French acronym for the United Nations mission here.
In the latest sex scandal to tarnish the world organization, at least 114 Sri Lankan troops have been expelled from the U.N. Stabilization Mission in Haiti on suspicion of sexual exploitation of Haitian women and girls.
This poorest nation in the Western Hemisphere has endured occupation repeatedly over the centuries, each time suffering instances of statutory rape and economically coerced sexual relations.
But this time, the troops had been sent to protect the country’s people. The United Nations had taken measures to stop such abuse after revelations three years ago that its troops in Congo were having sex with girls in exchange for staples such as eggs and milk or token sums of money.
When the abuses in the Haitian capital’s impoverished Martissant neighborhood were brought to the mission’s attention in August, a unit of the U.N. Office of Internal Oversight Services was deployed to investigate. Its report to the U.N. Department of Peacekeeping Operations in New York remains confidential, but mission commanders repatriated 111 soldiers and three officers on disciplinary grounds in early November.
MINUSTAH spokesman David Wimhurst said all violators of U.N. ethical policies are swiftly punished.
“The rules are very strict and very clear. There’s a zero-tolerance policy,” he said of the code of conduct to which all of the nearly 9,000 U.N. soldiers, police and civilians deployed in Haiti must adhere.
The Echo Foundation 79 “One by One by One……..” “You can’t have sex with anybody under 18 or with anybody in exchange for money, services, promises or food.”
The internal U.N. action has inspired Haiti’s fledgling feminist organizations to demand reparations from Sri Lanka and an investigation by Haitian authorities of suspected abuses among the 30-plus national contingents that make up MINUSTAH.
“The Sri Lankan case is the one we are hearing about now, but it’s not the only one,” said Olga Benoit of Haitian Women’s Solidarity, recalling two Pakistani peacekeepers who were expelled two years ago for raping a mentally ill woman in Gonaives and a French policeman disciplined for keeping a prostitute captive. “These are men, soldiers in big vehicles, carrying weapons—that has a lot of power in a patriarchal society like ours.”
In a country where more than half of the 8.5 Brazilian Peacekeepers clear fields during a civic day million people live on less than a dollar a day, the in the notorious slum of Cite Soleil. The fields will be parents and friends of girls engaging in sex for used as soccer pitches by Haitian NGO Athletique food or other compensation “tend to close their D’Haiti. Port-au-Prince, Haiti. Oct. 18, 2007. From eyes and pretend nothing is happening,” the UN. Benoit said.
Anecdotal reports on the Sri Lankan scandal indicate girls in their early teens were often involved, and that in the poorest areas of the capital the going rate for sex was a dollar.
Young girls have congregated outside peacekeeping posts since the first U.N. troops arrived in the summer of 2004, sometimes begging, other times flirting or practicing a few words of English, French or Spanish. After dark, scores of young girls in skimpy shorts or dresses can be seen loitering in the streets, waving to signal their availability to off-duty soldiers.
Magalie Marcelin of the Women’s Home organization, which is working to educate young Haitian women about their rights and the social risks around them, attributes the MINUSTAH scandal to a long history of Haitians regarding women’s bodies as commodities.
“That a soldier can do this to a girl he’s supposed to be protecting comes from the same mentality that allows a professor to do it to his student or a father to his daughter,” Marcelin said. ”In this society, women’s bodies are regarded as meat.”
Despite a successful campaign against the spread of AIDS in Haiti, sex remains a taboo subject. There is no sex education in the schools, and parents remain reluctant to discuss the topic, Benoit said.
Haitians able to scrape together a living blame parental lapses for the incidents of prostitution involving the troops. But they too tend to attribute the sex-for-compensation to their country’s gnawing, unmet needs.
The Echo Foundation 80 “One by One by One……..” “I know these things happen, and it’s very difficult times for many people,” said Guerde Clerveau, a mother of nine who sculpts wooden artifacts and sells them outside the main base of MINUSTAH. “But I would never allow my daughters to act like that, to sell themselves, even if we were starving.”
As with most nations contributing troops to U.N. peacekeeping missions, the Sri Lankan government retains responsibility for disciplinary action against its soldiers here. Authorities in the Sri Lankan capital, Colombo, in consultation with the commander of the 950-member Sri Lankan contingent, ordered the repatriations and deployed a high-level investigative team, including a female officer, to determine the extent of the abuses. That inquiry has yet to be completed, said Wimhurst, the MINUSTAH spokesman.
A spokeswoman for the Sri Lankan mission at the United Nations in New York, Mahishini Colonne, said she didn’t know when her government’s investigation would wrap up or who, other than officials in Colombo, would receive the report. She said reparations to Haitian victims was probably “one aspect being considered.”
But a senior diplomat at the Sri Lankan Embassy in Washington disputed that any compensation was due alleged victims and said the Haitian government was “also to be blamed.”
Speaking on condition of anonymity, the diplomat said poverty and the Haitian government’s inability to create opportunities for its citizens led young girls to sell themselves to lonely and homesick soldiers. He also said that the scope of the misconduct had been exaggerated and that some troops who never left their bases were among those identified from photographs by Haitian women.
Marie-Laurence Jocelyn Lassegue, the Haitian minister of women’s affairs, said she believed the abuses might be more widespread than reported, not less.
The U.N. has not shared its findings with the Haitian government. Lassegue said such a move was a necessary first step for Haitians to gather evidence to pursue reparations and dissuade further misconduct.
She has appealed to Haitian girls and women who have been involved in prohibited relationships with U.N. soldiers to come forward to provide testimony in a legal case to be brought before Sri Lanka and any other offending nations.
“The ones we know about have been traumatized and will need time to heal before they can take part in any campaign to alert others to the dangers,” she said. “We don’t yet have any perspective on the size of the problem, and my worst fear is that there are many others out there we don’t even know about.”
The Echo Foundation 81 “One by One by One……..” Report Indicts U.S. Government and Inter- American Development Bank for Violations of the Rights to Clean Water and Health in Haiti
From Partners In Health June 2008 By Tom Spoth
In 1998, the Inter-American Development Bank (IDB) awarded $54 million in loans to the Haitian government to improve the country’s patchwork, crumbling public-water system. The money was intended to bring clean water to people who for many years had been denied this basic human right, with devastating consequences for public health. Ten years later, however, this desperately needed money has not produced a single improvement to Haiti’s water A water source in need of an supply in the city designated to be one of the first recipients. intervention in Haiti. From PIH. A new report from Partners In Health and three other groups reveals the United States government’s clandestine efforts to ensure that political considerations (namely the desire to destabilize Haiti’s elected government at that time, led by President Jean-Bertrand Aristide) took precedence over the rights of some of the planet’s poorest and most vulnerable people.
In the 10 years since the loans were approved, the Haitian water system has actually gotten worse. In 2002, a water-poverty index released by the British-based Centre for Ecology and Hydrology ranked Haiti dead last out of 147 countries surveyed.
On June 23, Partners In Health—along with its Haitian sister organization Zanmi Lasante, the Center for Human Rights and Global Justice, and the Robert F. Kennedy Memorial Center— released the 87-page report “Wòch nan Soley: The Denial of the Right to Water in Haiti” in New York City.
“We have to stand up for what’s right,” Loune Viaud, director of operations at Zanmi Lasante, said at the press conference. “What is right is for the IDB and the international community to stop playing with the lives of innocent people.”
Viaud and the rest of the investigative team worked for six years to bring the story of the IDB loans to light. During that time, Haiti’s water system continued to deteriorate. The report states that: • Public water systems are rarely available throughout the year and close to 70 percent of the population lacks direct access to potable water at all times
The Echo Foundation 82 “One by One by One……..” • The percentage of the population without access to safe drinking water has increased by at least seven percent from 1990 to 2005 • Infectious diarrhea was the second leading cause of death in Haiti in 1999, and gastrointestinal infection was the leading cause of mortality for young children. These preventable diseases result primarily from unsafe drinking water and poor sanitation.
The failure to address Haiti’s crippling public-health problems is the latest in a long line of oppressive policies toward the country. Haiti, the only nation to be born from a successful slave revolution, has been hamstrung by crushing foreign debt for virtually its entire existence. It took Haiti more than 100 years to pay off a debt of 150 million francs (equivalent to $21 billion today) imposed by France in 1825 to “compensate” for the value of lost property, including the former slaves themselves. More recently, impoverished Haiti has been forced to pay $1 million a week toward settling a $1.54 billion debt piled up mainly by the dictatorial Duvalier regime, which did nothing to improve the lives of average Haitians.
Massive debt has precluded spending on desperately needed infrastructure projects. In 2003, for example, Haiti’s debt service was $57.4 million; the Haitian government’s combined budget for education, health care, environment, and transportation was $39.21 million. Meanwhile, the Haitian people continued to endure crushing poverty, which has been exacerbated by the failure to disburse the IDB loans. The report contains a telling comparison: In order to purchase the World Health Organization’s minimum standard of 20 liters of water per day, a Haitian family of four would have to spend approximately 12 percent of its annual income—the equivalent of asking a U.S. family living at the poverty level ($20,444 per year) to pay nearly $2,500 per year for water.
In Port-de-Paix, the Haitian city that was supposed to be one of the first beneficiaries of IDB loans, the Downtown Port-de-Paix, Haiti. From Photography/Nick Edens. private sector provides 80 percent of drinking water, and 86.7 percent of residents surveyed reported that they are “always” or “sometimes” unable to pay for water. Eighty percent indicated that water quantity had either declined or stayed the same in the five years before the survey was conducted, and 88.9 percent said water quality had gotten worse or not improved.
A household survey conducted by PIH documented the devastating impact on public health. Fifteen percent of the surveyed households reported probable recent cases of typhoid. One-third of respondents suffered from symptoms of gastrointestinal infection, the leading cause of death for Haitian children under the age of five.
The Echo Foundation 83 “One by One by One……..” “I’ve been working in Haiti for more than a decade,” commented Evan Lyon of PIH, “so I have long been aware of the connection between lack of access to clean water and preventable disease. But surveying households in Port-de-Paix opened my eyes to how essential clean water is to all facets of life, from cooking and washing, to growing food and the ability of children to attend school. At one household, we perched on rickety chairs in front of the house, ankle-deep in water, and the family was literally bailing filthy water out of their yard while I asked them questions. When we tested water at the local hospital we discovered it was just as contaminated as the water that makes people sick in the first place. The hospital’s water comes from the same dirty sources.”
Although initial bids have been taken for the Port-de-Paix project, as of May 2008, no ground had been broken. Several attempts to obtain updates from the IDB’s Public Information Center were unsuccessful. (In an article about the report, The Miami Herald quoted an IDB spokesman as saying that in Port-de-Paix, funds are being disbursed to contractors and work should be completed by 2009.)
By failing to distribute loans and grants to Haiti, the IDB violated its own charter, which strictly prohibits the bank from letting politics influence its decisions. Internal documents from the U.S. Treasury Department and the office of the U.S. Executive Director at the IDB, Most of the men in Port-de-Paix (and Haiti for that matter) have very obtained through Freedom of little work. As a result, most just hang out all over. Here you can see Information Act requests, show that a group of taxis waiting for work. From Photography/Nick Eden. officials actively used American influence to block the loans in an attempt to destabilize the government led by President Aristide, who was ultimately overthrown in 2004.
International law also protects the human right to water, according to the United Nations’ Committee on Economic, Social and Cultural Rights, as well as other international covenants and declarations. If one accepts the notion of water as a fundamental right, then the U.S. government’s actions can be construed as a direct violation of its international human-rights obligations.
“I bet most of the people in this city do not think about this as a right,” Viaud said. “It is taken for granted every day. Just imagine one day without water, here in New York City. It would be a disaster—in the news around the world. It would be outrageous.”
The report’s authors recommend a “rights-based” approach to water projects in Haiti going forward: All initiatives should focus on accountability and sustainability, and should involve Haitians living in the communities where projects will be implemented in the process.
The Echo Foundation 84 “One by One by One……..” War Fever: Malaria in Conflict
From BBC News Apr. 25, 2008 By Chris and Xand Van Tulleken
On World Malaria Day, Chris and Xand Van Tulleken, working with the aid agency Merlin, highlight the devastating link between conflict and rates of malaria infection.
When we were studying tropical medicine in London, a favourite trick of one professor was to ask students what we thought the deadliest animal in the world might be.
One Ghanaian colleague suggested a lion riding on the back of an elephant, eating and trampling everything in sight.
But the required answer was the humble mosquito—or more precisely, the anopheles mosquito, the carrier and transmitter of malaria, a disease which kills over one million people every year. Conflict causes 30% of malaria deaths in Africa. From BBC News/Jacqueline Koch. This rather clever answer isn’t entirely true. Anopheles mosquitoes are found in harmless abundance in many places on earth. Malaria, once widespread even in Kent [England], has been eradicated from Europe and North America, as well as many parts of Asia.
Why then does it persist with such deadly effect in some parts of the world?
Information Vacuum
Poverty and weak health systems contribute hugely to the problem, but another, largely overlooked, factor is responsible for nearly 30% of all malaria deaths in Africa—conflict.
In 2007, 26 million people were driven from their homes by conflict. The effects of climate change—and conflict over limited resources like water, food and land—mean that every year, larger numbers of people are likely to be displaced.
When people flee conflict, they don’t take hospital records with them. They don’t take demographic data or disease patterns or any of the other details needed to tackle malaria. They are often settled on land which has been abandoned because of the risk of malaria, or forced to live in over-crowded camps with limited health services, water, food and shelter.
The Echo Foundation 85 “One by One by One……..” In this vacuum of information and mass displacement, malaria is at its most deadly: frequently, more people die from the disease than the actual violence.
The British medical aid agency, Merlin, has been running emergency mobile clinics in Kenya’s Rift Valley province since post-election violence forced hundreds of thousands to flee their homes.
More than 32,000 terrified people flooded into Nakuru district in the Rift Valley alone. Medics working on the ground simply don’t have records of drug resistance levels or immunity for the displaced families now living in camps.
Cases of malaria are normally quite low in Nakuru, but with so many new people in the area, Merlin is aware that the chance of disease patterns changing is high, as is the risk of an outbreak.
Monsieur Paracheck
Experience shows that there is no single effective solution to controlling malaria; mosquitoes, resistance to drugs and people’s immunity all vary greatly from place to place.
Insecticide-treated bed nets have a vital role to play in preventing malaria, as Gordon Brown’s recent pledge of $200m to fund mass net distribution demonstrates.
But nets don’t work so well if, like many displaced people, you have no bed, and no home.
Likewise, destruction of mosquito breeding sites can control the disease, but first you must know whether the local bugs breed in dirty, sunlit ground water or clean water in dark places. Drugs used in one part of the world may be useless in another. From BBC News. Applying insect repellents to skin helps, but only if you know when the mosquitoes are likely to bite; anopheles gambiensis bites indoors at night (so bed nets work well), anopheles bellator bites outdoors at dusk.
Diagnosis poses similar problems.
Parachecks are rapid-test malaria kits, much like pregnancy tests. I used them to monitor for a malaria outbreak in Darfur; they were quick and easy for local staff to learn to use. My colleague who performed the tests was so proficient that he was popularly, and respectfully, known as Monsieur Paracheck.
These tests are not however appropriate in all settings and their usefulness depends on the number of people affected with the disease, the types of malaria, and the diagnostic information needed.
The Echo Foundation 86 “One by One by One……..” Treatment, again, varies. Drugs which can be effective within hours in one part of the world, may have such high resistance elsewhere to render them useless. Malaria prevention, diagnosis and treatment require intensive, local information gathering which is often extremely difficult when people are still migrating or when violence is rife.
But all are essential to understand quickly and implement early if, as predicted, the trend for mass displacement caused by conflict continues to rise.
Insecticide on Burkas
Solutions have to be tailored to specific circumstances.
An effective programme for Afghan refugees in Pakistan, rested on the discovery that the malaria mosquitoes there mostly feed on animals, and the displaced communities often live with their livestock so are constantly exposed to bites.
“Research showed that by coating the livestock with insecticide, malaria rates plummeted”, explains Merlin’s malaria advisor, Dr. Ahmed Fayaz.
“But there were also unexpected benefits: the animals gained weight and milk production Long Lasting Insecticide Treated Bed Nets increased. These welcome side-effects ensured (LLITN). From the Ivory Coast Medical Relief farmers continued to use the insecticide which Team. protected them from malaria.” Sadly, these methods won’t work in Africa, where mosquitoes tend to feed on people.
Nonetheless it is ideas founded in local knowledge such as these, or the technique of applying insecticide to women’s burkas in Muslim countries, which can help save lives. Malaria is a curable illness and a preventable disease. Even in desperately vulnerable, displaced communities, it is possible to greatly reduce the number of people who die from the disease with well- designed, locally effective control programmes.
As conflict forces more people from their homes, the need to put malaria control at the heart of any humanitarian response has never been more urgent.
The Echo Foundation 87 “One by One by One……..” Burma Junta Forces Health Workers Underground; Volunteers Risk Their Lives to Dispense Aid
From The Washington Times Mar. 3, 2007
With an empty plastic bag in her hand and a purse on her shoulder, she crosses into Burma every morning among the stream of Indian traders. To officials on both sides of the border, she’s just an ordinary businesswoman hurrying to shop in the popular Chinese markets in Namphalong, Burma.
But as soon as the 35-year-old tribal woman is beyond the sight of Burmese immigration officials, she neatly folds the vinyl bag and puts it in her handbag, before turning into one of the nearby villages to start her day’s work as a Burmese women working in fields. Public domain community health worker. picture. “Every day I meet intravenous heroin users, prostitutes and ordinary villagers to explain how they can prevent infectious diseases like HIV or hepatitis,” said the Burmese woman who lives in Moreh, a border town in the northeast Indian state of Manipur. Concerned about her safety, she did not want to be photographed or identified by name.
“I also advise people on how to get medical help in Burma or India in case they get the diseases.”
As a growing number of international charities suspend operations in Burma because of increasing pressure from Burma’s military junta, community health workers like this woman do their best to provide basic medical care to some of Asia’s most vulnerable people.
AIDS, Malaria Rife
In a country where HIV/AIDS and malaria are rife, the activities of any health worker are overwhelming. UNAIDS, the United Nations agency coordinating the global fight against the disease, estimates that about 620,000 people in Burma 15 to 49 years of age are infected with HIV. But on the border, where the junta casts its shadow over every section of society, health workers face the additional burden of risking their lives daily when they go to help the ill.
“Sometimes in the villages, I also distribute essential medicines supplied by NHEC,” the woman said, referring to the National Health and Education Committee, organized by Burmese pro-
The Echo Foundation 88 “One by One by One……..” democracy activists in exile. “Although I’m doing exactly what a community health worker does elsewhere in the world, I often have to work undercover to save myself from being troubled by the military.”
To maintain her false identity as a trader in the eyes of the Burmese border police, she carries cheap clothes or consumer goods from markets in Tamu, south of Namphalong, every evening for some shops in Moreh.
Junta Cracks Down
Lamlhing Touthang, a Namphalong-based health worker, recently returned home after participating in a monthlong HIV-care training camp in Manipur. On her return, she was interrogated for more than five hours by Burmese military intelligence officials, who suspected her of having a role in “anti-national” activities, suggesting that she doubled as a political agent for the pro-democracy activists in exile.
“From my bag [Burmese intelligence officers] got nothing except some NHEC pamphlets on awareness about AIDS and malaria,” she said. A Burmese ox cart. Public domain picture.
“Yet they ordered me not to go out of the country again for ‘so long’ in the future. They also told me not to maintain any communications with the NHEC.”
Now Ms. Touthang and her Burmese colleagues have officially become volunteers at a small Burma-based health nongovernmental organization a new role that helps keep intelligence officers at bay.
“Just to avoid trouble in the field, our health workers flaunt the identity cards of some Burmese NGOs,” said Dr. Aung Kyaw Oo, India-based chairman of NHEC’s western region. “But NGOs operating under many restrictions imposed by the military regime have no access to the developed world in which they could obtain modern care and treatment for HIV victims in Burma.
“Except for a few hospitals in cities, there are no trained government doctors to handle HIV victims. As many as 85 percent of HIV carriers live in rural areas. If the junta allowed international medical aid groups to function freely inside Burma, the problem would have not have become so acute.”
Charities Forced Out
Under pressure from the junta, many international medical charities are winding up their operations in Burma. In 2005, Global Fund for HIV/AIDS, Tuberculosis and Malaria canceled its $37.5 million program in Burma, citing government restrictions on its movements that made
The Echo Foundation 89 “One by One by One……..” functioning nearly impossible. Doctors Without Borders pulled out of Karen and Mon states last year for similar reasons.
In October, the International Committee of the Red Cross (ICRC) was ordered to close all its offices outside Rangoon after it reported rampant infection of HIV and other infectious diseases among prison inmates in the country.
Then in December, after the shutdown was criticized by many international agencies, Burma hinted it could allow the reopening of ICRC field offices, but would not allow the organization to make prison visits or give them access to detainees.
According to UNAIDS, the western part of the country is most neglected as far as HIV and AIDS treatment is concerned. The agency reported Protests against the Myanmar/Burmese military recently that not a single AIDS patient received junta. Public domain picture. free anti-retroviral drugs from the government.
“If the rule book is followed, all HIV-infected children should be given ART [anti-retroviral treatment]. But not one of the estimated 8,000 to 10,000 children in Sagaing division and Chin state have access to these vital medicines. It’s a horrible example of indifference meted out to its HIV-positive children by a government,” said another Manipur-based NHEC executive, who asked to be identified only as Dr. Thura.
Quacks Spread HIV
“Many quacks are still spreading HIV dangerously in rural areas, and many villagers to get common medicines injected are still receiving help from intravenous heroin users who make injections with used needles and charge half of what it would cost at a doctor’s clinic,” she said. “In terms of awareness, most HIV-affected areas [in Burma] today are in the same phase that neighboring Thailand or India were in 15 years ago. At least on humanitarian grounds, urgent intervention is necessary.”
Early last year, two workers of the Burmese Solidarity Organization a pro-democracy group working with NHEC were abducted by Burmese commandos from Moreh. NHEC officials shut down their medical sites and moved to Indian villages farther from the border.
In early February, the Indian army shut a temporary NHEC medical camp at an Indian border village in Mizoram, where India-based NHEC doctors were training Burmese health workers who secretly provide medical care in Burma. India-based Burmese health activists charged that the Indian army forced the closure of the medical camp and harassed Burmese doctors and other health workers to please their Burmese counterparts.
The Echo Foundation 90 “One by One by One……..” But despite such threats, the NHEC has started to build homes where orphans of the HIV/AIDS crisis in the Indian border districts of Manipur and Mizoram will have refuge once they leave Burma. The orphanages will also function as hospitals where trained doctors will be on hand.
Epidemic ‘Worsening’
“With the logistical help of friends in India and some Western countries, we are going to start these orphanage-hospitals where we hope to be able to provide anti-retroviral therapy [ART] on a regular basis as well,” said Dr. Aung Kyaw Oo. “In the absence of ART, the epidemic in Burma is worsening.”
Dr. Thura said that in the past three months, NHEC workers received more than 2,000 requests Market day commerce at Lake Inle, Myanmar. from gravely ill Burmese AIDS victims in Chin Public domain picture/Justin Blethrow. and Sagaing.
“Since the numbers of such poor people seeking free ART are constantly on the increase [in western Burma] and it’s impossible for us to help such a huge population settle in India, we have also sent proposals to our friends seeking help in starting ART relief centers in border districts close to Burma,” Dr. Thura said.
She said 80 percent or more of suspected HIV carriers in Burma do not know they are carrying the virus, and sex workers do not carry condoms because it is considered proof of prostitution.
Funding No Problem
Shalom, another Manipur-based medical NGO trying to combat HIV and AIDS, is setting up two hospices in the border towns of Moreh and Champhai.
Its director, Dr. Vanlalmuana Pachhuau, said funding often is not a problem for such projects when they were targeted to serve the people inside Burma. “The miseries of HIV and AIDS victims in Burma are well-known around the world. A number of funding agencies are ready to fund our projects and by the middle of next year we hope to open hospices.”
But Dr. Aung Kyaw Oo fears the planned HIV relief projects run by NHEC in Indian border states run the risk of being targeted by the Burmese junta.
“When the SPDC [ruling junta] cannot allow an organization as apolitical as the ICRC to serve the Burmese people freely, it can never tolerate us because it thinks we are spies and a part of a Western network engaged in attempts to overthrow the military government,” Dr. Aung Kyaw Oo said.
“Since it will not be able to order the closure of our projects, because they’re not based in Burma, [SPDC] could go to the extent of placing a ban on patients seeking any relief from us or any agency outside the country.”
The Echo Foundation 91 “One by One by One……..” Congo Ceasefire Brings Little Relief for Women
From the Canadian Medical Association Journal July 15, 2008 By Amanda Truscott
Sexual terrorism. It’s the only way to describe what is happening to women in the Democratic Republic of Congo, according to doctors at Panzi Hospital in the eastern province of South Kivu.
“If you combine HIV and sexual violence in Eastern Congo, this is a condition that is sufficient to affect the whole of humanity, to destroy a whole society, to destroy a whole people, slowly but surely,” says Panzi surgeon Dr. Roger Luhiriri.
Although the shooting war supposedly ended with a peace agreement in January 2008, “the war on women continues,” says Stephen Lewis, former United Nations special envoy for HIV/AIDS in Africa. That’s why his foundation donated another $300,000 in Congolese women in prayer. June 2008 to the Panzi Hospital. From Afrol News/Unjin Lee. “The wanton ferocity of the sexual violence allows for the frequent transmission of the virus,” Lewis adds. It finds an easy passage through women’s torn bodies, which are often subject to what Lewis calls “vaginal destruction.” Their entire reproductive systems are shredded by attacks with guns, branches or batons, he says. Often, the women are raped in front of their families.
The hospital gives free treatment to about 3500 survivors of sexual violence each year, a third of them children, 10% of them HIV- positive. A 2006 UN study found 50,000 reported cases of rape since the beginning of the conflict, but it acknowledged that number as only a small fraction of the total, since most cases go unreported. Lewis estimates the total number at about 200,000.
Lewis wants the UN to double its 17,000 troops in the Congo through the “Responsibility to Protect” principle, which gives the international agency the right to intervene to stop human rights abuses in countries where national governments lack the will or the power to do so. “In the Congo, rape is no longer merely a weapon Two Congolese rape survivors, both HIV positive, in a small of war. Rape is a strategy of war, employed to humiliate entire clinic in Luvungi. From Afrol families and communities through their women in order to take News/Unjin Lee. possession of resources, or to turn the women into sex slaves,” he says. The money from the Stephen Lewis Foundation will go to
The Echo Foundation 92 “One by One by One……..” everything from nurses’ salaries to school fees for the women’s children. One of its most important uses will be to provide more counselling, not just for the women, but also for the doctors who treat them.
“A work day at Panzi is nothing that you can ever imagine,” says Luhiriri, who manages Panzi’s maternity ward and performs about 10 surgeries per week, usually for obstetric and traumatic fistula—tearing in the vagina, anus or urinary tract. “The doctors themselves or the nurses practising have to deal with their own trauma, because at any given time, you could be in front of maybe your sister, your neighbour, your aunt, your friend’s girlfriend or wife,” he says. “Right now, I care for the physical state of the person, but mental disease is really difficult to care for,” Luhiriri adds. Terrazita, age 20, was raped and held as a sex slave by rebel militias in the forest for 13 months. Lewis says the international community’s indifference to the Terrazita escaped to Panzi Hospital plight of women in the Congo is the result of simple misogyny. and received fistula surgery. She is Still, he sees reasons to be hopeful. This spring, the United States holding her child, who was born of is scheduled to put forth a resolution to the UN Security Council rape. From Afrol News/Unjin Lee. to designate sexual violence a security issue. “And although it may be odd to be coming, in some respects, from the United States, it is nonetheless a signal that the issue now has huge international resonance,” he adds.
The Echo Foundation 93 “One by One by One……..” Chapter Two Discussion Questions
1. What kinds of diseases or illnesses are common in the Third World? Compare and contrast those with diseases/illnesses in the United States. Why are those lists different?
2. (For the next three, numbered questions see “A Dose of Reality” article p. 42.)What social inequalities associated with women make them more susceptible to HIV/AIDS?
3. Who is responsible for ensuring women are treated as equally as men in society? Why is this important?
4. What impact does a faltering educational system have on a community and on a region?
5. Why are girls more likely to be pulled out of school than boys?
6. (For the next two, numbered questions see “AIDS in Africa: A Quest of Trust” p. 55.)What is traditional medicine? Why do some people chose traditional medicine over western medicine?
7. How do these different types of medicine conflict with each other?
8. Why are refugees and migrants more susceptible to diseases than other people?
9. Why do health professionals in developing countries move to more developed countries?
10. Why is it important for a country to retain its health professionals?
11. What can developing countries do to motivate health professionals to stay?
12. When addressing poverty and disease in a nation, why is it important to build infrastructure (like roads, healthcare services, sanitation, etc)?
13. How can corruption affect a country’s healthcare system? Who benefits from corruption and, conversely, who suffers from corruption?
14. Why is it difficult to treat diseases like malaria during conflict?
15. What are the devastating effects on a community when rape is used as a weapon of war?
In addition to this discussion questions’ page, please see the “Socratic Seminar” activity on p. 179. This activity highlights two articles from this chapter—not covered in this discussion questions’ page—that discuss the efficacy of international aid.
The Echo Foundation 94 “One by One by One……..” III. Healthcare Initiatives in the Third World
rom the WHO. World Health Organization (WHO) Switzerland. Geneva, in headquarters F
A n inmate stands in front of Children in Madagascar a poster reading prepare for a community ‘Tubercolosis’ in a outreach event in the fight tuberculosis prison hospital against HIV. From USAID- in Tomsk, Siberia. From Santénet. Reuters/Thomas Peter.
People displaced by tsunamis in Banda Aceh, Indonesia, queue for water from Steven Epps, a leading air craftsman with the Australian Air Force. From The AP.
1 billion people live on less than US$1 a day, with 2.6 billion—40% of the world’s population—living on less than US$2 a day. (UN Human Development Report, 2007)
The Echo Foundation “One by One by One……..” Community Health Workers
From Partners In Health, 2006
Throughout the developing world, deflated national budgets and caps on government spending imposed by international financial institutions have led to an exodus of healthcare professionals and the collapse of health care delivery systems. In Haiti’s Central Plateau, there is just one doctor for every 50,000 people (compared to one for every 358 in the United States and the World Health Organization’s recommended ratio of 1 to 1,000). Patients must walk for hours to reach a clinic, often to discover that no staff or medications are available. In a cruel irony, these dismal conditions are used to justify further neglect by those who argue that this “infrastructure gap” makes it impossible to deliver life-saving treatment to the poor. From PIH.
Improving salaries and working conditions for doctors and nurses is one key to closing that gap. Partners In Health’s model of community-based care emphasizes another underutilized and undervalued resource for overcoming barriers to healthcare delivery – patients and other community members trained and paid to serve as community health workers. At PIH sites in Haiti, Peru, Chiapas, Boston, Rwanda, and Lesotho, community health workers connect clinics with local communities by serving as counselors, educators, treatment providers, and advocates experienced in local needs. By delivering services to patients in their homes, community health workers improve adherence to treatment and reduce the burden of time and money on both patients and health care systems.
Overcoming Barriers to Health Care
Many barriers stand in the way of poor people seeking medical care – transportation costs, social stigma, lack of information, discrimination by medical personnel, and shortage of time. Even when treatment is available free of charge, these and other barriers too often prevent people from accessing the health care that they need and to which they are entitled.
The Echo Foundation 96 “One by One by One……..” For nearly two decades, PIH community health workers have helped patients overcome these and other barriers to care by accompanying them through treatment, monitoring their needs for food, housing, and safe water, leading education campaigns, and empowering community members to take charge of their own health. As members of the communities they serve, community health workers can establish relationships of trust with their patients, bridging the gap between the clinic and the community.
Community health workers can also help health care systems overcome personnel and financial shortages by providing high-quality, cost-effective services to community members in their homes, and by catching serious conditions at an early stage, before they become more dangerous and expensive to treat. In addition to strengthening health infrastructure, community health worker programs also boost the local economy by creating paying jobs.
Delivering Life-Saving Treatment Every Day
One of the key services provided by PIH community health workers is daily supervised treatment for patients living with HIV/AIDS and tuberculosis (TB). Medications for HIV and TB must be taken with precise regularity to be effective. Their side effects can be debilitating, or even deadly. Furthermore, if these complex treatments are not taken correctly, a patient can develop resistance, rendering the medication ineffective. For years, these obstacles were used to justify denying access to treatment for people living in poor countries. But the success of PIH and other organizations using community health workers helped demolish the excuses and change the policies. From PIH.
At PIH sites in Haiti, Rwanda, Boston, and Lesotho, all patients beginning treatment for HIV or TB are paired with a community health worker. Every day, these community health workers visit patients in their homes to supervise treatment, ensuring they take their medications regularly and correctly. Over time, they teach their patients how to manage complex treatments, cope with side effects, and identify the signs and symptoms of impending illness. This support enables people with HIV or TB to live longer and healthier lives, with less chance of developing resistance to their medications.
In Haiti, Zanmi Lasante community health workers first began providing daily medications for people living with HIV in 1999. At that time, prevailing wisdom in public health claimed it was impossible to provide high-quality treatment and follow-up for people living with HIV in developing countries. But the success of ZL’s patients proved otherwise. Today, more than 800
The Echo Foundation 97 “One by One by One……..” community health workers from ZL visit more than 1,600 patients every day to administer antiretroviral medications, and monitor the health of a total of 8,000 people living with HIV. Thanks to their careful follow-up, most patients who come to ZL in need of antiretroviral therapy begin treatment in less than two weeks, and over 98 percent of patients have continued taking treatment for life.
Engaging the Community in the Struggle for Health and Human Rights
While making daily rounds to the homes of HIV and TB patients, community health workers strengthen connections between the clinic and the community, helping improve understanding of the barriers to health faced by local people. By accompanying patients day by day, community health workers develop a deep awareness of the effects of illness and poverty in their community. Because of their local knowledge and personal commitment, community health workers may be able to support their communities in addressing broader barriers to health, including oppression, violence, and social and economic injustice.
In Chiapas, Mexico, community health workers, or promotores, play a prominent role in health education efforts in communities served by PIH’s partner EAPSEC. Promotores work to improve health conditions by conducting workshops and trainings sessions on themes such as building local health care systems, mental health, sexually transmitted infections, conflict resolution, and environmental health.
In Boston, community health workers from PIH’s Prevention and Access to Treatment and Care (PACT) program have created a network of support, education, and intervention for people in some of the poorest areas of the city. PACT’s Fuerza Latina program trains patients who are in the early stages of recovery from drug use to do outreach among their peers, providing street- level HIV counseling and testing, HIV prevention education, condom distribution and needle exchange in the Boston area. Since the program’s inception, the promotores of Fuerza Latina have provided more than 1,000 people with street-level counseling and accompaniment to detox or HIV counseling and testing services, and have distributed more than 9,000 safer sex kits.
Fair Pay for Heroic Work
Health care programs that rely on community health workers have achieved success throughout the world. Yet continuing pressure on developing countries to cut expenditures has discouraged many governments from investing in public health. As a result, many of those who do make use of community health workers classify these positions as “health volunteers,” denying fair payment and adequate training for the essential and compassionate work of visiting patients daily in their homes. International donors and many nongovernmental organizations with much greater resources have followed suit.
The Echo Foundation 98 “One by One by One……..” From PIH.
There is no excuse for withholding payment for the highly skilled services of community health workers, who accompany patients through their greatest struggles and put themselves at daily risk of contracting deadly diseases. Furthermore, payment to community health workers directly benefits the health and welfare of the community by providing a source of income for people who are often patients themselves or are at risk of disease from hunger and other symptoms of poverty. PIH provides and advocates for professional treatment of community health workers— including fair payment, ongoing training, and provision of necessary supplies—so they may perform their vital work to the highest standards. In some communities, training and employment of community health workers makes PIH not only the main health care provider but the biggest employer and source of adult education.
The Highest Standard of Care: Community-Based Care
Community health workers provide a highly effective and affordable way for health care systems to ensure high standards of patient care. But the benefits to patients, communities, and health workers themselves extend beyond simple cost-effectiveness. Community health workers build trust between healthcare professionals and the community they serve. They educate and empower their neighbors to identify and overcome barriers to health.
By providing treatment to patients in their homes, community health workers also protect them against one of the greatest risks for catching and spreading disease – spending time in a hospital or clinic. Infections acquired during a hospital stay (known as nosocomial infections) are extremely common, and not only in developing countries. In the United States, an estimated 10 percent of hospital patients (or about two million people a year) are infected during their stay, at a cost of around 90,000 deaths and $4.5 billion a year. Hospitals are also breeding grounds for drug-resistant pathogens. Again in the US, more than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them.
By improving adherence to treatment, monitoring medical and socioeconomic needs, empowering patients, and reducing the risk of hospital-acquired infections, community health workers make possible a model of comprehensive, community-based care that is the highest standard of care available anywhere, especially for patients suffering from chronic disease.
The Echo Foundation 99 “One by One by One……..” Siberian Jail is Champion in TB Fight
From Reuters News Agency July 3, 2008 By James Kilner
TOMSK, Russia―Alexander Pushkarev, head doctor at the 1,000-bed hospital in a Soviet-era prison nestling at the edge of Siberia, flashed a row of metal teeth with his smile.
“Welcome to Tomsk Correction Facility No. 1,” he said. “This is the best treatment for TB in Russia.”
In the mid-1990s, virulent tuberculosis was killing prisoners here every week, but with the help of a group of American doctors, the jail near one of the world’s biggest swamps has set an example to others worldwide dealing with drug-resistant TB.
Following an initiative from the U.S. Public Health Research Institute which was funded by George Soros, the Tomsk project now run by Boston-based doctors’ group Partners In Health (PIH) has overturned conventional medical thinking that drug-resistant TB strains are extremely difficult and expensive to treat.
“Without the Tomsk project, drug-resistant TB treatment would be years behind where it is now,” said Jussi Saukkonen, a doctor from Boston who was in Tomsk to inspect the project.
“It’s been an important benchmark in dealing with this problem.”
Under the project, which has now extended beyond the prison to the general population in the region, deaths from TB in Tomsk have nearly halved in eight years to around 12 per 100,000 people ― a third of the average in Siberia.
Its main thrust is simple: just to ensure existing treatment is adhered to properly, rather than introducing new high-tech solutions or expensive drugs.
About 2 million people die each year from TB, a rate which is accelerating, making it one of the world’s biggest killers: there are around 3 million deaths a year from AIDS and 1 million from malaria.
Drug-resistant TB emerged over the last couple of decades mainly because patients failed to complete courses of medication, so the Tomsk Correction Facility is an appropriate place for this project: one of its core weapons has been discipline.
The most effective response was produced by rigorously enforcing a series of existing measures, including improving ventilation, ensuring medical staff have proper training, paying for essential drugs and establishing a strict monitoring system to make sure patients complete their treatments.
The Echo Foundation 100 “One by One by One……..” Among the non-prison population, doctors do rounds and physically watch their patients take their TB medicine. State benefits are withdrawn if the patient skips their treatment, while testing and education about TB have improved.
Doctors use a range of antibiotics and are ready to switch patients between treatments if they don’t respond.
The World Health Inmates enter their ward in a Tuberculosis prison hospital in the Siberian city of Organisation (WHO) Tomsk some 2175 miles east of Moscow June 4, 2008. From Reuters/Thomas now promotes such a Peter. strategy, called the DOTS (Directly Observed Treatment, Short-course) programme.
Killer of Chopin, Orwell
Previously known as consumption, TB killed millions including the 19th-century Polish composer Frederik Chopin, Scottish author Robert Louis Stevenson and 20th-century English writer George Orwell.
Rising living standards and antibiotics virtually wiped out TB ― bacteria spread via droplets which commonly attack the lungs invoking a bloody cough and sapping energy ― in the developed world during the second half of the 20th century.
But it still stalks poorer countries, where people infected with HIV are most vulnerable, and figures show there are more people with the disease now than ever.
The WHO estimates that nearly half a million people a year worldwide become infected with a form of TB that is resistant to two or more of the primary drugs used to treat it.
Parts of the former Soviet Union are among the worst affected areas: around 15 percent of new cases in Tomsk are drug resistant, against a world average of just over 5 percent. Baku in Azerbaijan has the world’s highest rate of drug resistance in new cases, at 22 percent.
But PIH says it has achieved nearly an 80 percent cure rate for drug-resistant TB. The group, founded to provide medical care to the poor, is using the experience from Tomsk to set up
The Echo Foundation 101 “One by One by One……..” projects to treat drug-resistant TB in the African countries of Rwanda and Malawi, and other former Soviet states.
Since PIH took it over, the Tomsk project has also been funded by the Bill & Melinda Gates Foundation and pharmaceutical group Eli Lilly, and in 2004 received a grant worth $10.8 million over five years from the Global Fund to Fights AIDS, Tuberculosis and Malaria, set up by the world’s wealthiest countries.
The Russian prison service now sends inmates from other regions to the jail to receive treatment, and the regional authorities plan to set up a global TB research unit there this year.
Eight Years and Counting
In a wing of the prison cordoned off from the rest of the hospital, a few dozen inmates infected with drug- resistant TB have been locked away. People only enter wearing protective clothing ― plastic hats, overalls and face masks.
Before the U.S. doctors launched their project here, An inmate sits in the multi-drug resistant tuberculosis (MDR-TB) ward in a prison hospital in the Siberian city of Tomsk some 2175 miles east of Moscow few inmates could expect to June 4, 2008. From Reuters/Thomas Peter. leave this wing alive.
“Maybe that’s why Tomsk was so receptive,” said Ed Nardell, another PIH doctor. “They were literally counting the bodies and knew that something had to be done.”
Groups of men dressed in black overalls stared out from behind high wire fences which segregate courtyards or peered through mucky, barred dormitory windows. Their heads were shaved, their expressions blank, their faces gaunt and hollow.
A prisoner who gave his name as Rakhid said life in the hospital prison has vastly improved: “I’ve been here eight years,” he said and then chuckled. “And I’ll be here a while longer.”
The Echo Foundation 102 “One by One by One……..” Why Madagascar’s HIV Rates Are Low
From the Guardian’s International Development Journalism Competition, summer 2008 By Aline Reed
An unusual activity is taking place on a stretch of wasteland to the east of Madagascar’s capital, Antananarivo. A group of children is peeling bananas and stuffing them in their mouths as fast as they can. That they are hurrying is understandable. The assembled boys and girls come from the nearby slums of Ankazomanga, where the average family has six or seven children. As in any large family where food is scarce, children soon learn that the quickest gets the most to eat.
What’s unusual here is that each boy and girl is being timed and, although they may not realise it, eating bananas is intended to protect them from becoming infected with HIV.
As such, the banana-eating competition is part of a much wider race. One that has millions of lives at stake as well as the reputations of the 189 world leaders who signed up to the eight Millennium Development Goals. Goal six includes a commitment to halt and begin to reverse the spread of HIV/Aids by 2015. With six years to go, the latest UN chart shows “no progress, a deterioration or a reversal” in sub-Saharan Africa.
It is the region where progress is most urgently needed. Last year, a third of all new cases of HIV infections and a third of all Aids-related deaths occurred here. The Global Fund alone has invested almost US$3bn in combating Aids, TB and malaria. For the children of Ankazomanga, however, the greatest protection was given to them as a birthright.
Madagascar has amongst the lowest rates of infection in HIV-blighted sub-Saharan Africa. The government’s latest estimate is that 0.14% of men and women aged over 15 are HIV positive. Compare this to the 26% adult infection rate in Swaziland and a question emerges. Why?
It’s generally agreed that Madagascar has its geographical isolation to thank for its low rate of HIV infection. A secondary factor, however, is the widespread practice of male circumcision. The World Health Organisation (WHO) is now investigating advocating circumcision after a series of trials funded by the US National Institutes of Health revealed a 60% reduction in risk of HIV infection.
It’s been estimated that, if full coverage were achieved, male circumcision could prevent two million people from becoming HIV positive in sub-Saharan Africa in the next 10 years.
Catherine Hankins, associate director of the policy, evidence and partnerships department at UNAids, adds a warning note, “Male circumcision does not provide complete protection against HIV. Men and women who consider male circumcision as an HIV preventive method must continue to use other forms of protection such as male and female condoms, delaying sexual debut and reducing the number of sexual partners.”
The Echo Foundation 103 “One by One by One……..” On the ground, this message continues to be at the heart of HIV prevention work together with investment in testing and treatment. By taking an HIV test in public, Madagascar’s President, Marc Ravalomanana, has shown commitment exists at the highest level. But his government’s description of HIV and Aids as a “feeble presence” in its latest UN update strikes an unfortunate note of complacency. There is growing evidence to suggest that Madagascar is on the brink of an epidemic of its own.
The island’s first line of defence has been breached. The 250 mile sea that divides Madagascar from Mozambique has provided a natural barrier to the disease that has overrun the mainland. Net migration has been close to zero for many years, but recent government initiatives to counter the country’s crippling poverty is bringing an influx of foreign workers.
High rates of syphilis suggest that HIV could spread quickly. In July last year, the government was forced to declare a state of emergency in Fort Dauphin, when 17,000 people contracted syphilis. A local mine which attracted international workers and prostitutes alike to the town is thought to be the centre of the outbreak.
Syphilis, at least, can be contained and treated in circumstances like these. HIV cannot. “Mini- epidemics” have already been observed with HIV infection rates amongst adults rising to 1.1% in the city of Sainte Marie and 0.8% in Morondova. According to UNAids, Madagascar’s young people could be the key to averting catastrophe just as they are believed to be behind the decline in HIV prevalence in eight sub-Saharan countries. For the children of Ankazomanga, though, HIV prevention comes in an unusual form.
Fun is not a major feature of life in Ankazomanga. Hunger, disease and absolute poverty are. So the banana-eating competition is enough to draw a crowd of over a thousand of the slums’ inhabitants. Once it’s completed, young men take their places for a “pousse-pousse” race. These carts are usually used to carry goods to market. Today, they are moving so fast that the home- made banner marking the winning line is a blur to participants, but it reads “unsafe sex is risky for HIV/Aids”.
This safe sex message is being promoted by a group of teenagers who have only just learnt it themselves. They attend a YMCA centre built by UK-based charity, Y Care International. Nirina Ravotomalala, centre manager, says: “Our new centre is in a bad place, but it is the right place”. With no electricity supply, no sanitation, no schools and no health centre, it is certainly a bad place for young people to grow up. But at the centre, the people of Ankazomanga can now gather, organise themselves and fight HIV/ Aids.
A few days later, the young organisers of the banana-eating event are evaluating their success. On the plus side, attendance and participation was high. So high, in fact, that the teenagers admit to finding it difficult to control crowds and fear their overall message was lost on many. Here at least though, lessons are being learnt. Amongst them, enthusiasm is undimmed and, when it comes to HIV prevention, tenacity is perhaps the most important quality of all. The next event is debated and agreed upon—a singing competition. With each of the songs expected to promote safe sex, this time the message will be impossible to ignore.
The Echo Foundation 104 “One by One by One……..” Combating HIV/AIDS, Malaria and Other Diseases Through ‘Edutainment’ in Rwanda
From the Guardian’s International Development Journalism Competition, summer 2008 By Jenny Holden
Mugeni has just found out that she is HIV positive. She is 17 years old and has recently been made pregnant by Muhire, the village shopkeeper. Scared of Muhire’s reaction and fearing the scorn of her community, she is forced to keep this to herself. Mugeni is then confronted with a major dilemma. Muhire demands that she have sexual intercourse with him. Mugeni knows that this would increase the chances of transmitting HIV to her unborn child, but to request he use a condom or to refuse her boyfriend sex would be socially unacceptable.
What should Mugeni do?
Mugeni and Muhire are known throughout Rwanda as the stars of a radio soap opera, Urunana (hand in hand). The stories of Mugeni and Muhire and other characters are being used to educate Rwandans on a number of health issues including contraception, Malaria, HIV testing, nutrition and the prevention of mother to child transmission of HIV. The programme airs twice a week on BBC World Service and Radio Rwanda and is listened to by approximately 74% of the nine million population. Mugeni and Muhire are the “Ricky and Bianca” or the “Scott and Charlene” of Rwanda and even in the most remote villages of Rwanda you will find both old and young discussing “what should Mugeni do?”
Rwanda is among the poorest countries in the world. Following the devastating genocide of 1994, which cost Urunana has a cult following in the Great almost a million lives, many of Rwanda’s 34 hospitals and Lakes with about 10m listeners. From 188 health centres were looted. Most of the staff were killed BBC News. or exiled. The loss of health professionals reduced dissemination of preventive health information. This has contributed to some very poor health indicators in Rwanda.
Rwanda has an average life expectancy of 46 years and a HIV prevalence rate estimated at 3.1%. A study in 2001 found that almost two thirds of boys and girls, from the age of 13 and 14 respectively, have had unprotected sexual intercourse. Over half of the girls and a third of boys do not know anything about contraception and roughly a quarter of children have no knowledge at all of the issues surrounding HIV/Aids.
Urunana has been broadcast in the Great Lakes region of sub-Saharan Africa since 1999. Initially started by a British NGO, Health Unlimited, Urunana Development Communication became an independent organisation in 2004 and by 2009 the organisation will be completely self-sufficient. Over the past 10 years it has become a leading institution in development communication. It is
The Echo Foundation 105 “One by One by One……..” capable of addressing health and social issues in an unusual way by appealing to cross-sections of the traumatised post-conflict Rwandan society and others in the war-torn Great Lakes region.
This radio programme has enabled men, women and children to become informed about sexual and reproductive health issues including HIV/AIDS, sexually transmitted infections, safe motherhood, menstruation, domestic violence and rape. Combined with Umuhoza (Agony Aunt), the accompanying Q&A magazine show, the programme has helped to dramatically improve the overall health and life chances of listeners, through the concept of “edutainment”.
For a young woman from Nygatere District, Northern Rwanda, Mugeni’s story had made a particular impact. Grace is 16 years old and like Mugeni, an older man has recently made her pregnant. She was scared at first, and tried to deny her pregnancy. After hearing what happened to Mugeni, she decided to go to the health centre and to tell the father that she was pregnant.
After hearing on Urunana that mothers with HIV can pass it on to their children, Grace knew she should have an HIV test at the health centre. She managed to persuade her partner to come with her, and he agreed because he had also heard the story. Neither of them was found to be HIV positive. Grace and her partner now plan to get married. Grace told me: “We now listen to the radio together, and it has helped us to become closer.”
Urunana has been very successful in increasing discussion of reproductive health issues in a very difficult environment. Almost half of the target population is illiterate and issues around sexual and reproductive health are still taboo and difficult to discuss face to face. The radio soap bypasses these barriers by providing information in an entertaining and non-confrontational way.
Increasing discussion around health issues and sexual and reproductive issues in particular is critical to achieving the sixth Millennium Development Goal of combating HIV/Aids, Malaria and other diseases. As Urunana has demonstrated, radio can be a powerful weapon in this fight due to its ability to promote health messages to populations in even the most remote and marginalised areas of developing countries. The show brings people together, helps them to share their experiences and enables them to be better equipped to overcome the many health challenges that they face.
The Echo Foundation 106 “One by One by One……..” Drug Patent Rules Must Allow Exceptions for Public Health
From the Center for Economic and Policy Research Mar. 2008 By Mark Weisbrot
Some big pharmaceutical companies are up in arms about developing countries importing less expensive generic versions of drugs for which these companies hold a patent monopoly. But the procedure is perfectly legal, even under the World Trade Organization’s pro-pharmaceutical- monopoly rules. The only question is whether these huge corporations – who used their political muscle in Washington to prevent our government from lowering the price of Medicare prescription drugs—will intimidate other governments that are trying to provide essential medicines to their citizen.
Thailand became the latest target of this bullying last winter when it issued “compulsory licenses” for three drugs. Two were anti- AIDS drugs (efavirenz and lopinavir/ritonavir) and the third is used to treat patients with cardio-vascular disease (clopidogrel). A compulsory license allows for the production or import of a generic version of a patented drug, without the permission of the patent holder. It is completely legal, and in fact the United States has used Delhi Network of Positive People and Lawyers Collective HIV/AIDS Unit compulsory licenses many demonstrated their support for the Thailand government’s move to increase patients’ access to essential medicines by issuing compulsory licenses for times. patented AIDS drugs. condemned US-based Abbott Laboratories Inc. for blocking new medicines to the Thai market, including important HIV/AIDS But the U.S. government has drugs. From The AP/Gurinder Osan. sided with the big pharmaceutical companies and put Thailand on a special “Priority Watch List,” which could potentially lead to trade sanctions against Thailand. Actual sanctions are unlikely, but Washington and its pharmaceutical allies have made a serious threat. Now that pressure is reportedly being used to block similar licenses for three cancer drugs.
Thailand is a developing country of 65 million people, with income per person of about $10,000,
The Echo Foundation 107 “One by One by One……..” or less than one-fourth that of the U.S. The government estimates that the use of generic efavirenz will enable it to provide this anti-AIDS medicine to an additional 20,000 people, as compared to using the pharmaceutical giant Merck’s branded version (called Stocrin).
The vast majority of developing countries have not exercised their rights to compulsory licensing, because of the pressure from PhRMA (the U.S. trade association of the big branded pharmaceutical companies) and the many politicians that are under its influence. This is a tragedy. Former President Bill Clinton, speaking in support of the governments of Thailand and Brazil in issuing compulsory licenses, noted that “no company will live or die because of high price premiums for AIDS drugs in middle-income countries, but patients may.”
The pharmaceutical companies argue that they need to protect their patents in order to fund the research and development that produces new drugs. This is partly true – although the majority of pharmaceutical research goes to produce “copycat” versions of other drugs that already exist. These copycat drugs can generate big profits but don’t necessarily provide any advantage over existing drugs. The system is so inefficient that Americans are currently paying about $150 billion dollars through monopoly pricing to the companies, in order to get about $25 billion worth of research – much of which is not especially helpful.
So big PhRMA is really making an argument for more comprehensive reform: if the economic and social costs of funding research through private monopolies is so high, maybe we should put more into public and non-profit research (which already accounts for a substantial amount of the research these companies use). In fact, if our own government were to fund the research that the branded pharmaceutical companies now carry out, and allow the results to be used for generic drugs, the research would more than pay for itself. The government would save more than the cost of this research through lower prices for the drugs it buys through Medicare and Medicaid. And the drugs would be available immediately as generics to the rest of the world.
Such economically sensible reforms may be some years off, given the power of the pharmaceutical lobby. But the least we can do right now is to stop this lobby from bullying other governments that are trying to do the right thing for their citizens.
Mark Weisbrot is co-director of the Center for Economic and Policy Research, in Washington, D.C. He received his Ph.D. in economics from the University of Michigan. He is co-author, with Dean Baker, of Social Security: The Phony Crisis (University of Chicago Press, 2000), and has written numerous research papers on economic policy. He is also president of Just Foreign Policy.
The Echo Foundation 108 “One by One by One……..” WHO Promotes New Strategies to Combat Threats to Global Public Health
From Voice of America News May 28, 2008 By Lisa Schlein
The World Health Organization calls the adoption of a strategy that will help developing countries access life-saving drugs a breakthrough. WHO officials say several other resolutions adopted by the 193-member World Health Assembly will go a long way toward tackling longstanding, new and looming threats to global public health. Lisa Schlein reports for VOA from WHO headquarters in Geneva.
Millions of poor people in developing countries suffer from diseases that rarely afflict people in wealthy countries. Developing countries say pharmaceutical companies spend vast sums of money on treatments for problems such as baldness and acne that cater to the wealthy.
But, they say, little research is done to create drugs against parasites and tropical diseases that kill and disable millions of poor people each year because there’s little money to be made from this.
Dr. Elil Renganathan is WHO Executive Secretary for Public Health, Innovation and Intellectual Property. He says the World Health assembly adopted a new strategy that will address the immediate need for equitable access to good quality, affordable medicine.
He says it will encourage research and development of medicines for the common diseases of the developing world. Millions of people need access to life- “If this strategy is put in action, we will have new saving drugs. From BBC News. medicines to deal with the diseases for which we do not have enough medicines at the moment,” said Elil Renganathan. “That is a big thing. Poor countries will have medicines that will be available for diseases for which at the moment we may have one or two medicines.”
These diseases include multi-drug resistant TB and second-line drugs for diseases such as AIDS and malaria.
Governments also endorsed an action plan to tackle non-communicable diseases. The World Health Organization reports cardiovascular diseases, including high blood pressure, diabetes, cancer, and chronic respiratory diseases account for 60 percent of global deaths every year.
The Echo Foundation 109 “One by One by One……..” It predicts in the next 10 years, deaths from these four diseases will increase by 17 percent. It says the greatest increase will take place in developing countries, mainly in the African region.
WHO Assistant Director-General for Non-Communicable Diseases and Mental Health, Ala Alwan, says the six-year action plan is aimed at preventing non-communicable diseases and providing health care for those who fall ill.
“These diseases are largely preventable,” said Ala Alwan. “And, for the millions of people who already have the disease, there are cost-effective interventions that would improve their management and that would delay or at least prevent complications.”
Alwan says the four major risk factors for non-communicable diseases are tobacco use, unhealthy diet, lack of physical activity and the harmful effects of alcohol.
The world health assembly also pledged to intensify its work to curb the harmful use of alcohol, which is the fifth leading risk factor for death and disability in the world. It called upon the World Health Organization to develop a global strategy for this purpose.
The Echo Foundation 110 “One by One by One……..” User Fees: A Necessary Evil?
From The Lancet Dec. 13, 2007 By Jienchi Dorward
“Please, he’s an itinerant worker, his family is in the city and he can’t pay for the transport to get home, let alone this treatment.” Yet another patient unable to afford the care that they needed—a common scenario during my elective in Bolivia. I look at the doctor, who shrugs his shoulders. “Somebody has to pay,” he says. Standing in front of this sick young man, who owed less than I spend on an average night out, it seemed obvious that it shouldn’t be him. However, user fees such as this, where patients have to pay for drugs or treatment up front, are widespread in low income areas. Instead of being a problem, many in the global health field have argued that user fees are part of the solution when providing healthcare for the poor.
In the 1980-90s many low-income countries, encouraged by the World Bank,1 started charging people for drugs and services at government health facilities. Supporters argued that these user fees would generate much needed revenue for health systems weakened by economic difficulties, as well as improving quality and efficiency. 1 However, there was little evidence for these policies and critics quickly pointed out their potentially catastrophic effects on the poor.2 As these changes were introduced, more evidence emerged to fuel the debate. Some studies showed Paz, Bolivia. Free use picture/Paul Richter. an increase in use and quality of services after the introduction of user fees.3,4 In Cambodia, user fees replaced informal charges, meaning that patients’ money was reinvested into the healthcare system for the benefit of all, rather than vanishing into healthcare workers’ pockets. Quality improved, and so more people used the service, generating more revenue which could be re- invested in a cycle of positive re-enforcement.4
Competition with private healthcare services was also intended to improve quality. As government health services depended more on user fees for their income, it would be in their interest to attract more patients by making their services better value for money. However, critics argued that this would encourage staff to improve the quality of income generating, high visibility services, whilst ignoring more cost effective preventative measures like vaccinations.
Evidence also emerged which highlighted the negative effects of user fees on the poor, who often struggle to pay for the treatment they need. In one example from a poor rural district in Kenya, the introduction of user fees led to a drop in the use of services.5 Exemptions, where certain groups are not expected to pay, were supposed to protect the poor and vulnerable. However, even though children under five and the extremely poor were exempted from newly introduced
The Echo Foundation 111 “One by One by One……..” charges, the use of services amongst these groups dropped as well.5 This highlighted some of the problems with exemptions; they stigmatise people, they increase administrative costs through the added bureaucracy of assessing who is eligible, and they have to be well publicised to prevent exempted people being deterred by fees they don’t need to pay.
As well as excluding the poor, user fees can also contribute to poverty. Firstly, they force people to redirect their resources to health care, meaning they may not have money to buy seed for their next harvest or to send their children to school. Having to pay large amounts at short notice can force people to sell valuable assets or borrow at high interest rates, often driving them into poverty. Also, by preventing people from accessing healthcare, user fees can keep people in a state of ill health, thereby decreasing their ability to work productively and participate in society.
Another argument used to justify user fees is that they increase efficiency by discouraging ‘frivolous’ use of health services. However, many poor people live in rural areas and have to use large percentages of their income on transport costs to get to health services, making ‘frivolous’ use unlikely.6 The extra revenue generated by user fees has also proved elusive, with evidence showing that in Africa they only provide 5% of government health expenditure.6 Many governments and international institutions (including the World Bank) now acknowledge the difficulties in implementing user fees and their Empty beds (in Bolivia) because the patients can’t potential harmful effects on the poor, with several afford them. From The Lancet. countries (e.g. Uganda, Zambia) removing them altogether.6
This has also required careful thought. Sudden, poorly planned changes can wreak havoc on a health system,7 as increased demand and a potential decrease in revenue can over-run health facilities with more work than they can manage. Instead of simply removing user fees, alternative systems of funding can be put in place.8 National social insurance schemes, which are widely used in high-income countries, are funded by contributions from employers and employees.
However, in low-income countries many people are not formally employed and are therefore excluded from the health system. In these situations, smaller scale community insurance schemes may be better. Here members regularly pay a small fee to have their future health costs covered. Yet good evidence showing the effects of these schemes on use and quality of services is scarce.9 In the case of Uganda, extra funding for health from central government was used to replace lost revenue and cope with the increased number of patients when user fees were removed.10 However, relatively better off people, who live nearer health services and are better able to access care may benefit more from this than the poor who need care the most.
The Echo Foundation 112 “One by One by One……..” In Cambodia, the trend has been to maintain user fees and complement them with equity funds, where resources are set aside to pay for exemptions for poor people, as well as helping them to access care and pay for transport costs.10
Innovative solutions like the example from Cambodia demonstrate that the global health community must move beyond a polarized debate ‘for or against’ user fees. Instead, the cultural and political context of the different alternatives for funding healthcare must be better investigated and understood. Economic and health inequalities, as well as social values such as how much one social group should subsidise another group’s healthcare, are different across the world, and must be considered when making health policy.
In Bolivia, our patient was eventually able to pay after his community got together to raise funds. Global policy makers, donors and governments must do the same and work together to learn from local and global evidence and find innovative ways to ensure that we all get the healthcare we need.
Works cited in this article
(1)Akin J, Birdsall N, Ferranti D, (1987). Financing health services in developing countries: an agenda for reform. Washington, DC: World Bank. (2) Creese A, (1991). User charges for health care: a review of recent experience. Health Policy Plan; 6:309-19. (3) Akashi H, Yamada T, Huot E, Kanal K, Sugimoto T, (2004). User fees at a public hospital in Cambodia: effects on hospital performance and provider attitudes. Soc Sci Med; 58:553-64 (4) Litvack J, Bodart C, (1993). User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Soc Sci Med; 37: 369-83. (5) Mbugua J, Bloom G, Segall M, (1995). Impact of user charges on vulnerable groups: the case of Kibwezi in rural Kenya. Soc Sci Med; 41: 829-35. (6) Brikci N, Philips M, (2007). User fees or equity funds in low-income countries. Lancet; 369:10-1. (7) IRIN News (2006). BURUNDI: Side effects of free maternal, child healthcare http://www.irinnews.org/report.aspx?reportid=59267. (8) Gilson L, McIntyre D, (2005). Removing user fees for primary care in Africa: the need for careful action. BMJ; 331:762-5. (9) Palmer N, Mueller DH, Gilson L, Mills A, Haines A. (2004). Health financing to promote access in low income settings-how much do we know? Lancet; 364:1365-70. (10) Meessen B, Van Damme W, Tashobya CK, Tibouti A, (2006). Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia. Lancet; 368:2253-7.
The Echo Foundation 113 “One by One by One……..” BURUNDI: Side Effects of Free Maternal, Child Healthcare
From IRIN News Agency June 9, 2006
A new policy of free medical care for Burundian mothers and children was intended to improve their lives; instead it has crippled the nation’s health system. Public hospitals in Burundi have recorded double, sometimes triple, the number of patients since a presidential directive for free paediatric and maternal health services was implemented on 1 May. Overcrowded wards, a shortage of doctors and other medical staff, as well as patients’ inability to afford prescribed medications are some of the challenges health officials are now facing. The situation in rural health centres is particularly desperate. In one case, four heavily pregnant women with health complications were referred from a rural clinic to a larger and better-equipped city Carinne, 16, has been unable to pay hospital. However, the facility turned them away because of her hospital bills but hopes to benefit overcrowding. After local media reported that the women had from the Burundi Government’s not been admitted, a senior Ministry of Commerce official new, free birth-services policy. From ordered that they be taken to a private clinic. Unfortunately, it UNICEF/Ajia. was too late for one patient: She died as she was being taken there. The woman’s death could have been avoided had procedures been in place to ensure the proper implementation of the directive, health officials said. The public health system was ill prepared to cope with the resultant increase in patients, and subsequently, patients have been let down. The poor services patients were accustomed to paying for may now be free, but the quality of care has declined even further because of the increased caseload and an acute shortage of doctors.
An Unmanageable Caseload
Aline Bigirimana has brought her child, who is shivering with a high fever, to the Prince Regent Charles Hospital in the capital, Bujumbura. “Mothers who brought their children for treatment today are many, and by midday, the paediatrician will tell us to come back later,” she said. “But when we return in the afternoon, we will find the doctor has left. I am worried because today is Saturday. If I go home without my daughter being treated, I fear she may not be alive by Monday, when I’m supposed to come back.” Although implementing free maternal and child healthcare has been plagued with difficulties, many Burundians, including Bigirimana, have largely welcomed the initiative.
“Previously, I paid 700 Burundi francs [US$7] for consultation, but now I don’t have to pay a thing,” she said, as she inched along the long queue of patients waiting to see the only paediatrician on duty at the hospital. Many patients said the government should have included free prescriptions in its initiative. “Free healthcare, to me, should include free medicine,” said
The Echo Foundation 114 “One by One by One……..” Adidja Nsengiyumva, another mother seeking treatment for her child at Prince Regent Charles Hospital. Before the directive, many pregnant women simply could not afford to give birth in hospital and delivered their babies at home, despite the health risk. “I delivered my nine children at home for lack of hospital fees,” said a woman at Kayanza Provincial Hospital in the central part of the country. Her tenth child would be born in hospital because “the service is now free of charge”, she said.
Administrative Woes
The large number of women and children seeking free healthcare has overwhelmed most institutions. Hospital administrators nationwide have complained about congestion in paediatric and maternity wards. “We saluted the measure, but it seems the government did not plan mechanisms to successfully implement it,” said Tharcisse Nzeyimana, director and gynaecologist at the Prince Louis Rwagasore Clinic in Bujumbura. “Before the decision to provide free healthcare, our hospital received a daily average of seven women wanting to deliver,” Nzeyimana said. “The hospital now receives between 15 and 20 women per day.” Crowding at the clinic, which caters to rural and urban residents, peaks at the weekend. A similar situation prevails in other health institutions, such as the provincial hospitals of Kayanza, Bururi and Gitega. A shortage of bed space has forced the two overworked nurses at Gitega Hospital to put patients along corridors. Mothers must be discharged on the day they give birth to make room for others. The nurses complained of working long hours, an average of 10 hours daily, seven days a week. At Bururi Hospital in the south, the maternity ward receives between 40 and 66 patients per day, according to the provincial health director, Onésime Ndayishimiye. Prior to the initiative, the daily average was 14.
Lack of Equipment and Expertise
Free healthcare for women and children has made Burundi’s lack of qualified medical staff and specialists even more keenly felt. “Kayanza Hospital has only one doctor for the many C-section cases,” Firmin Ruberintwari, the hospital’s administrator, said. Like many of his colleagues at other facilities, Ruberintwari worried that the hospital would run out of medicines and other equipment. “Of three gynaecologic [delivery] Women with their children wait to see a tables needed, only one is in a good state,” he said. At paediatrician at the Prince Régent Charles the Ruyigi Hospital in the southeast, there is a shortage Clinic. From IRIN. of beds, mattresses, operating tables and even basics like surgical gloves. The hospital, which already struggles to pay its staff, now has the additional burden of funding the free services.
Government Unable to Pay Medical Bills
Before the 1 May directive, the government paid the medical bill for sections of its employees who sought treatment in public health institutions, including the police and the army. It also paid
The Echo Foundation 115 “One by One by One……..” for the medical care of destitute people. For example, the government owes Kayanza Hospital the local equivalent of at least $60,000. This, in turn, has led to hospitals in Cankuzo, Bubanza, Cibitoke, Ruyigi and Rutana provinces being unable to pay their suppliers, a situation that can only impact negatively on patients. “Suppliers are reluctant or just refuse to provide drugs and equipment, since the hospital is incapable of paying its bills,” Ruberintwari said.
Kayanza Hospital already owes its suppliers some 50 million Burundi francs ($40,000) and is fast running out of drugs. The situation is identical at the Gitega Hospital. Hospital administrators have demanded the government take urgent corrective measures. Nzeyimana, the administrator of Prince Louis Rwagasore Clinic, said the government should increase medical staff, compel all health centres to remain open 24 hours and reinforce weekend teams to cope with the growing influx of patients. In addition to recruiting more staff, the government needed to increase salaries in order to stem an exodus of doctors from government service, he said.
Ministry of Public Health officials say they are aware of the implementation problems and are looking for ways to resolve them. “First instalments of the amounts to be paid [to hospitals and clinics] are available at the Finance Ministry,” said Cyprien Baramboneranye, managing director for resources at the Ministry of Public Health. However, he said the ministry was waiting for facilities to invoice the government before clearing its bills. This instalment, he added, would enable hospitals and health centres to function normally.
The principal private secretary in the Ministry of Public Patients at the maternity ward in the Prince Health, Julien Kamyo, said the government was Régent Charles Clinic in Bujumbura. From providing $2 million to settle the issue of medicine IRIN/Barnabe Ndayikeza. shortages. In addition, foreign donors would give at least $8 million to the health sector this year. However, he said, it would take more than a year to solve all the problems associated with the directive.
The Echo Foundation 116 “One by One by One……..” WHO: New Quick TB Test Rolled Out in Africa
From the U.S. News and World Report June 30, 2008 By Frank Jordans
A new test to quickly diagnose drug-resistant forms of tuberculosis will be rolled out in four African countries this year, the World Health Organization said Monday.
The DNA-based test will cut the time it takes to detect multi-drug resistant TB from 2-4 months to a matter of hours, the director of WHO’s tuberculosis program said in Geneva.
Dr. Mario Raviglione said testing is currently “one of the major bottlenecks” in combating the disease, which becomes harder to treat the longer patients have to wait for the appropriate medication.
“This test is feasible, is affordable, and is effective in high endemic countries,” said Giorgio Roscigno of the Geneva-based Foundation for Innovative New Diagnostics, which helped develop the test.
Medical aid group Medecins Sans Frontieres welcomed the new speedier diagnosis, but said it remains to be seen how cost-effective the test will be.
More than 9 million people around the world fall sick with tuberculosis every year. Of those, about 500,000 get multi-drug resistant TB, which is immune to two types of antibiotic treatment. Patients with drug- resistant tuberculosis have to switch to more potent and expensive medicines.
Detecting drug-resistant TB quickly improves the chances a patient will survive and lowers the risk that the disease mutates further into an even more drug- A Cambodian man living with tuberculosis in resistant form of the disease. Extensively drug-resistant Phnom Penh. From MSF/Roger Job. tuberculosis, which affects about 40,000 people each year, is very difficult to treat with drugs. It has become a major threat to HIV patients in Africa, as well as among prison populations in the ex-Soviet countries of Eastern Europe.
The Stop TB Partnership—an umbrella group created to bring together different organizations in the fight against the disease—said it will train staff and equip laboratories in four African countries this year, starting with the small southern African nation of Lesotho.
The Echo Foundation 117 “One by One by One……..” Ethiopia, Ivory Coast and Congo will also begin using the $5 test before the end of the year, said Raviglione. A further $15 has to be spent on lab equipment and staff salaries, bringing the total cost to $20 compared with up to $34 for older methods.
However, training staff to carry out the tests will be a major challenge, said Dr. Tido von Schoen-Angerer of Medecins Sans Frontieres, also known as Doctors Without Borders. New labs and trained staff will be needed to run the tests, since TB is highly infectious and must be handled carefully, so the overall cost of the test is still unclear.
“The problems with the test are that they are very, very complex,” he said. “The desperate search for much simpler tests has to continue, but this at least is a good step forward in cutting down the time to diagnosis.”
Von Schoen-Angerer also said the new test is still unable to detect extensively drug resistant tuberculosis and cannot be used for patients who either cannot cough up any sputum or who appear to have no bacteria in their sputum. About half of HIV-positive patients with TB are “sputum negative,” meaning the new test will not work for them.
WHO said it hopes the test will be introduced in 16 African countries over the next four years. A tuberculosis patient at the Port Moresby hospital in Papua New Guinea. The World Dr. Karin Weyer, a South African TB expert who Health Organization has said that a new test reviewed the new tests for WHO, acknowledged the to screen for drug-resistant tuberculosis will limitations but maintained that they can be overcome. greatly help the fight against the disease in developing countries. From AFP. “The test is as reliable, if not more reliable, than the conventional test that we have now,” she said.
WHO’s Mario Raviglione said he expects even rich countries to switch to the new DNA-tests in future because they are so fast.
The Echo Foundation 118 “One by One by One……..” The $10 Solution
From Time Magazine Jan. 4, 2007 By Jeffrey D. Sachs
Listen for a moment to the beautiful and dignified voices of Africa’s mothers. Despite their burdens of poverty and hunger, they will tell you not of their endless toil but of their hopes for their children. But softly, ever so softly, they will also recount the children they have lost, claimed by a sudden fever, children who died in their arms as they were carried in a desperate half-day’s journey by foot from the village to the nearest clinic.
This is the ineffable sadness of malaria. Another African child has died of malaria since you started reading this article. Perhaps 2 million children in all will succumb this year.
The long-term consequences are insidious as well as tragic and even relate to the ability of the U.S. to prevail against the jihadists. Not only does malaria sap worker productivity and scare away business investment, but it also, paradoxically, increases the rate of population growth. Instead of having two or three children, couples in a malarial region often choose to have six or seven—unsure how many will survive.
Malaria also helps create a poverty trap with special ferocity in Africa. By a quirk of ecological Malaria nets. From Reuters/Rafiqur Rahman. fate, Africa has the world’s heaviest toll of this disease, the result of its tropical climate, its specific types of mosquitoes and its limitless mosquito-breeding sites. Children are struck down in unmatched numbers. And Africa’s disease toll from malaria may be even higher than previously recognized. Recent research has found that malaria infection increases the likelihood that an HIV-infected individual will transmit the AIDS virus to others. Many millions are also infected simultaneously with malaria and worm infections, multiplying the disease burden.
Osama bin Laden has called for jihad in Africa, trying to capitalize on its extreme poverty. Here’s how we can respond. While malaria has shaped Africa’s poverty trap, it is a trap that can finally be unlocked. Spectacular technological advances, some stunningly simple, offer practical and low-cost solutions. The most obvious one is insecticide-treated bed nets, now cleverly engineered to last up to five years. The cost to manufacture, ship and distribute each net is $10. A new generation of medicines based on artemisinin, an extract from a traditional Chinese herbal remedy, is remarkably effective in treating cases of the disease, at a cost of about a dollar per treatment.
The Echo Foundation 119 “One by One by One……..” Yet these solutions still aren’t reaching the vast proportion of Africans in need. Hard as it is for us to imagine, Africa’s households simply can’t afford even $10 for a net, or a dollar for medicines when a child falls sick. Nor can African governments carry these costs on meager budgets or take extra vital steps to train local health workers and ensure that every village has reliable access to effective medicines.
Here is where you and I come in. Considering the costs of the nets, medicines and other components of malaria control, a comprehensive program would cost about $4.50 per African at risk, or about $3 billion a year for the whole continent. This is an amount that is too large for Africa but truly tiny for the rich world.
Let me put the $3 billion in perspective: there are a billion of us in the high-income world—that amounts to $3 a person, or one Starbucks coffee a year. It’s around 12.5% of the estimated $24 billion in Wall Street’s Christmas bonuses.
We should bring forth armies of Red Cross volunteers to distribute bed nets and to offer village- based training for tens of thousands of villages across Africa. In a brilliant demonstration of people power and modern logistics, Red Cross volunteers distributed nets to more than half the households of Togo in 2004 and Niger in 2005 in a matter of a few days in each country. That successful delivery model should be replicated across Africa, by 2010 if not earlier, but this will depend on mobilizing the needed resources.
New citizens’ movements, including Malaria No More (malarianomore.org) and Nothing but Nets (nothingbutnets.net) have been established to achieve the needed breakthrough. We can each contribute $10 Malaria patient Elsante Karangira Pallangya sits with his mosquito net, which is riddled for a bed net. We can each learn more about the disease with holes. Pallangya must share two bed nets and become antimalaria leaders in our communities, with his family of five in the village of schools, churches and businesses. We can urge our Patandi, Tanzania. From Fall 2007 governments to work with the private sector and [International Reporting Fellow at Johns citizens’ groups to win the fight against malaria during Hopkins University] Eliza Barclay. this decade. President Bush recently took a good step in scaling up the U.S. government’s malaria-control efforts, but much more needs to be done to ensure that aid reaches the hundreds of millions of Africans at risk.
Together we can choose peace over jihad and life over violence. Through our common resolve, we can prove the power we each have to save a life.
Sachs, author of The End of Poverty, directs the Earth Institute at Columbia University.
The Echo Foundation 120 “One by One by One……..” A Life Saver Called “Plumpynut”
From CBS News June 22, 2008
You’ve probably never heard a good news story about malnutrition, but you’re about to. Every year, malnutrition kills five million children—that’s one child every six seconds. But now, the Nobel Prize-winning relief group “Doctors Without Borders” says it finally has something that can save millions of these children.
It’s cheap, easy to make, and even easier to use. What is this miraculous cure? As CNN’s Anderson Cooper reports, it’s a ready-to-eat, vitamin-enriched concoction called “Plumpynut,” an unusual name for a food that may just be the most important advance ever to cure and prevent malnutrition.
“It’s a revolution in nutritional affairs,” says Dr. Milton Tectonidis, the chief nutritionist for Doctors Without Borders. “Now we have something. It is like an essential medicine. In three weeks, we can cure a kid that is looked like they’re half dead. We can cure them just like an antibiotic. It’s just, boom! It’s a spectacular response,” Dr. Tectonidis says.
“It’s the equivalent of penicillin, you’re saying?” Cooper asks. “For these kids, for sure,” the doctor says.
Plumpynut. From CBS News. No kids need it more than a group of children 60 Minutes saw in Niger, a desperately poor country in West Africa, where child malnutrition is so widespread that most mothers have watched at least one of their children die.
Why are so many kids dying? Because they can’t get the milk, vitamins and minerals their young bodies need. Mothers in these villages can’t produce enough milk themselves and can’t afford to buy it. Even if they could, they can’t store it—there’s no electricity, so no refrigeration. Powdered milk is useless because most villagers don’t have clean water. Plumpynut was designed to overcome all these obstacles.
Plumpynut is a remarkably simple concoction: it is basically made of peanut butter, powdered milk, powdered sugar, and enriched with vitamins and minerals. It tastes like a peanut butter paste. It is very sweet, and because of that kids cannot get enough of it. The formula was developed by a nutritionist. It doesn’t need refrigeration, water, or cooking; mothers simply squeeze out the paste. Many children can even feed themselves. Each serving is the equivalent of a glass of milk and a multivitamin.
To see the impact it’s having, 60 Minutes drove for 12 hours from Niger’s capital to a remote village, where every week Doctors Without Borders hand out Plumpynut. After sleeping in a field under mosquito nets, Cooper and the team awoke at sunrise to find mothers emerging from
The Echo Foundation 121 “One by One by One……..” the fields. Many had walked for hours in the dark, along treacherous paths, avoiding scorpions, spiders and poisonous snakes.
Rivers of women flowed into the site and within minutes there were more than a thousand of them, all waiting to get packets or tubs of Plumpynut. In a land where plastic bags are a luxury, they carry the food home in their scarves, their hands, or simply stacked on top of their heads.
“When you see some of these kids they don’t look sick. They don’t look malnourished. They don’t have bloated bellies or little stick arms,” Cooper remarks.
“The ones that we’re used to seeing on TV, that’s the worst of the worst of the worst. It’s the tip of the iceberg. And then below that, there’s the iceberg. So, there’s a whole spectrum of malnutrition,” Dr. Tectonidis says. “And when we go and check these kids, well, they’re way off in height or in weight. They’re way off.”
Niger has become Plumpynut’s proving ground. A daily dose costs about $1; small factories mix it here and in three other African countries. Tectonidis says other companies could make similar products wherever children need them. Faran, an eighteen month old “There’s many countries in Africa now saying, ‘We want a factory. boy, participated in an We want a factory.’ Well let’s give it to them,” he says. “We just International Medical Corps’ out-patient therapy program in have to focus on these areas. We don’t have to feed the whole world. Ethiopia where he received We have to go for the jugular. Where are they dying? Where are they Plumpy’nut, a therapeutic food wasted? That’s where we have to intervene. If you feed them well for children who suffer from until they’re two or three years old it’s won. They’re healthy, they malnutrition. From IMC/Julie can get a healthy life. If you miss that window, it’s finished.” Pudlowski.
In Niger, most children need help now during what’s called the “hunger season,” just before the new harvest. Old food supplies have run out and about all that’s left is millet, a basic grain women pound for porridge. But millet doesn’t have enough nutrients to keep kids alive; in America we use it as birdseed.
Normally a children’s hospital 60 Minutes visited would have more patients than beds. But now, thanks to Plumpynut, it has empty beds. Dr. Susan Shepherd, a pediatrician from Butte, Mont., runs Doctors Without Borders in Niger.
She says children that would have been hospitalized in the past can now be treated at home. “The reason we can do that is because we can give children Plumpynut here in the ambulatory center, and they take a week’s ration home. Moms treat their children at home and come back every week for a weight check,” Dr. Shepherd explains.
That’s what Sahia Ibrahim has been doing. She’s already lost four children to malnutrition. Now
The Echo Foundation 122 “One by One by One……..” her six-month-old twins, Hassana and Husseina, are malnourished and she’s worried they might die too. So she’s been coming to the hospital for Plumpynut.
Hassana, at six months old, weighs only seven pounds. While that’s what a newborn should weigh, the little girl has put on a pound in just a week thanks to Plumpynut.
Children are weighed and measured at the distribution sites. They’re also examined to make sure they don’t have any serious infections. Malnutrition destroys a child’s immune system, so they’re more susceptible to diseases and less capable of recovering from them.
“Often these kids aren’t even hungry. It’s the opposite. They are anorexic because of the deficiencies they have. They lose their appetite,” Tectonidis explains.
That’s what happened to Mansour Miko and Maroufee Mazoo. Less than a year old, they had stopped eating and became listless and weak ― so weak that when their mothers brought them to get Plumpynut, the nurse put them in a van and sent them straight to the hospital. Three days later however, they were smacking their lips on Plumpynut, almost ready to go home.
“Have you seen kids who were on the brink of death brought back by Plumpynut?” Cooper asks. “Oh, yeah, for sure. Again and again and again and again,” Dr. Shepherd says.
But not always. Sometimes parents wait too long before bringing their child to doctors. 60 Minutes found Rashida Mahmadou in intensive care, barely clinging to life.
Rashida’s condition was very serious. Her skin was literally peeling away ― one side effect of malnutrition, as skin becomes thin, pliable, cracks easily, and bacteria invade.
Just two hours later, Rashida’s little heart stopped beating. She was just 19 months old. “She died of severe, acute malnutrition,” says Shepherd, who says she sees this happening every day.
Asked how she deals with so many kids dying, Shepherd tells Cooper, “It breaks your heart. It can break your spirit. It can ruin your confidence in your ability to be a good doctor. At any given moment, more than 60 And it is sad. And I carry memories of many, many children million young children in the world have with me and I’ll carry them with me for my entire life. But signs of acute malnutrition and are at you certainly cannot indulge yourself in that kind of sadness. serious risk of death unless they receive We need to do something about this.” specialized care. But ready-to-use therapeutic foods and outpatient treatment strategies now allow many If Plumpynut is the answer, how come kids are still dying? more acutely malnourished children to “The answer is getting to kids earlier,” Shepherd says. “Once be treated than ever before. From children are as sick as she is, Plumpynut is not going to save MSF/Philip Horak. her.”
The Echo Foundation 123 “One by One by One……..” Rashida was buried in a nearby cemetery, where the grave digger told 60 Minutes he is burying fewer children than he used to. Two years ago this region had the highest malnutrition rate in Niger. But now, after widespread use of the Plumpynut, it has the lowest. Dr. Shepherd told Cooper they’ll be able to treat more than 120,000 kids this year, up from just 10,000 children three years ago.
What about peanut allergies?
“We just don’t see it,” Shepherd says. “In developing countries food allergy is not nearly the problem that it is in industrialized countries.
It’s hard to imagine a less industrialized country than Niger. On a list of 177 developing countries, Each 500-calorie foil sachet of Plumpynut is about the United Nations ranked Niger dead last ― least the nutritional equivalent of a glass of milk and a developed. More than 70 percent of the people multivitamin. From Mercy Corps/Thatcher Cook. don’t know how to read. Most work in the fields and earn less than a dollar a day. Nomadic goat herders still roam this land―their children and their kids travel by camel. Goats seem to be the main garbage disposal, but clearly the goats are falling behind. You can still spot a skinny guard dog, but we were told all the cats have been cooked.
In the countryside, where 85 percent of people live, girls start marrying as young as 11 years old. By the age of 15 most are wed, and by 16 most have already become mothers. The average woman here will give birth at least eight times in her lifetime. But largely because of malnutrition, one in five of their children will die before they reach the age of five. Of those who survive, half will have stunted growth and never reach full adult height.
But now, with Plumpynut, more children are surviving and thriving. “And kids are doing better. Moms say their child’s skin is brighter. Their appetites are better. And they’re less sick. You know, what more could you ask for,” Shepherd remarks.
Doctors Without Borders is asking for more of this type of food. Their success in Niger proves, they say, that fortified ready-to-eat products, like Plumpynut, save children’s lives. Dr. Tectonidis says if the United States and the European Union were willing to spend part of their food aid on this, more companies will start making it. “Even by taking a miniscule proportion of the global food aid budget, they will have a huge impact, huge impact!” Tectonidis says. “We’re not even asking for billions. It will solve so much of the underlying useless death. So we got to do that now.”
“It’s useless death,” Cooper remarks.
“Wasted life. Just totally wasted life for nothing. Because they don’t have this product, little a bit of peanut butter with vitamins,” Tectonidis says.
“What a waste.”
The Echo Foundation 124 “One by One by One……..” PEPFAR Reauthorization Bill Introduced as a Bold Plan to Fight AIDS; Women, Disproportionately Affected by AIDS, Stand to Benefit
From Physicians for Human Rights Feb. 26, 2008 By Kate Krauss
Physicians for Human Rights applauds the upcoming introduction of the United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (known as the PEPFAR reauthorization bill) in to the House of Representatives and strongly supports the bill’s call for at least $50 billion over five years. The bill that will be introduced on Wednesday was developed under the leadership of the late Rep. Tom Lantos, and passing it would be a tribute to a great champion of global health and human rights. On May 27, 2003, President Bush signs the U.S. Leadership Against HIV/AIDS, President Bush has proposed spending only $30 billion Tuberculosis and Malaria Act of 2003. From over five years for the program, a level which would the White House/Tina Hager. hinder HIV prevention efforts and slow treatment of new patients. Only 100,000 new patients per year could be started on HIV drugs, when millions are dying without treatment. “Only a small fraction of people with AIDS in Africa are getting the medicines that will keep them alive,” said John Bradshaw, JD, Director of PHR’s Washington Office. “Now is not the time to slow down.”
White House officials contend that the program cannot absorb more money, but PHR points to its research into Africa’s health infrastructure. “African countries urgently need more health workers to implement PEPFAR programs, and the new Lantos bill would help by training and retaining thousands of them,” said Bradshaw.
Among many useful provisions, the bill would greatly strengthen programs for women and young girls, who are physically, socially, and economically more vulnerable to HIV infection. Presently women compromise 61% of HIV cases among adult sub-Saharan Africans, and as many as 75% of the young people infected with HIV in the region are female.
The Echo Foundation 125 “One by One by One……..” The bill would support interventions that elevate the status of women, who are often at the lowest rung of society. It would, for instance, promote basic education for women and promote the property and inheritance rights of women, two factors which have been linked to vulnerability to HIV/AIDS.
The new bill would link AIDS services to other health services women need, such as family planning and maternal-child services. The bill would also support the integration of primary care and HIV prevention, care and treatment programs which have proven to decrease HIV incidence and stigma and reduce overall cost. Through HIV counseling and testing for couples at the U.S.-supported Kericho District Hospital in PHR is calling for PEPFAR 2 to train, retain, and Africa, Joyce and David found out they are infected support at least 140,000 new African health with HIV. Joyce was four months pregnant with her workers—the US’s fair share of health workers second child at the time of diagnosis. Thanks to the needed to achieve universal access to HIV clinic’s program to prevent mother-to-child HIV transmission, Joyce delivered a baby boy who is programs. PHR’s field work and feedback from the HIV negative. After a year of antiretroviral group’s large network of allies in Uganda and treatment, David has also gained weight and feels Kenya indicates that this is a critical problem that healthy, enabling him to provide for his family. often prevents the effective use of PEPFAR From PEPFAR 2007 Annual Report/Doug Shaffer. monies and should be addressed in reauthorization legislation.
In addition, the bill would support the development of five year plans from each country to address its health worker crisis, would provide technical assistance for countries that seek to strengthen their health workforces and would help them track and better utilize the health workers they do have.
The bill would also explicitly support safer working conditions for health workers, who often must tend to sick patients without masks, gloves, or other basic equipment. Background Rep. Berman is expected to introduce the House version of the bill on February 27 since he is acting chair of the House Foreign Affairs Committee―Rep. Lantos was a powerful force behind reauthorization of PEPFAR up until his death.
There are two versions of the bill, substantially different, circulating in the House; a Senate version is not expected for a couple of more months.
The Administration and Republicans in the House think PEPFAR is fine as it is and are resisting nearly all of the evidence-based changes Democrats (and global health organizations) are introducing. The Lantos bill pushes for far greater focus on HIV prevention among women, who comprise 61% of people with HIV in sub-Saharan Africa and as many as 75% of young people
The Echo Foundation 126 “One by One by One……..” with HIV in the region. Lantos’ bill would offer strong support to programs that scientific evidence has shown helps prevent HIV in women―and also protect their human rights. “Abstinence and Be Faithful” (AB) programs were a central focus of PEPFAR 1, but evidence from the field shows that these programs are inadequate to address the needs of women who have no ability to control who they have sex with, let alone demand that a condom is used.
The Lantos bill would fund programs that lift the status of women—like microloans and access to food—which have been shown to reduce HIV transmission. Where they have human rights, women have the ability to protect themselves. The Lantos bill would also integrate reproductive health services, and other basic health services, with AIDS care so that there is one-stop shopping for patients, and AIDS money can reach broader populations. This would also eliminate the stigma for women—and others—that prevents them from walking into an AIDS clinic—they would just be walking into any health clinic.
The Lantos bill would help stem Africa’s vast health worker shortage—a major stumbling block that is currently preventing PEPFAR money from reaching people with AIDS who need it, according to the World Bank and the World Health Organization. The World Health Organization estimates that Africa needs more than one million additional health workers—and the Lantos bill would push for a minimum number of such workers and fair distribution of them throughout rural areas. The Republican version of the bill strips out this language, potentially crippling the overall program.
PHR calls for PEPFAR 2 to train, retain, and support at least 140,000 new African health workers—the US’s fair share of health workers needed to achieve universal access to HIV programs. PHR’s field work and feedback from the group’s large network of allies in Uganda and Kenya indicates that this is a critical problem that prevents the best use of PEPFAR monies and should be addressed in reauthorization legislation.
The Echo Foundation 127 “One by One by One……..” Debt Swap Initiative Kicks Off in Indonesia
From the Global Fund To Fight AIDS, Tuberculosis, and Malaria June 23, 2008
Dr. Rahmat Waluyanto, Director General of Debt Management, Ministry of Finance Republic Indonesia, Ambassador Baron Paul von Maltzahn, Embassy of the Federal Republic of Germany in Indonesia, and Robert Filipp, Head of Innovative Financing of the Global Fund to Fight AIDS, Tuberculosis and Malaria announced the start of “Debt2Health” in Indonesia today.
Debt2Health is a new financing instrument which helps increase domestic spending on health in Indonesia by €25 million. Debt2Health functions similar to a debt swap: Germany has agreed to cancel €50 million of Indonesian debt while the latter has agreed to invest half of that amount in public health programs in Indonesia supported by the Global Fund.
“We are delighted to be piloting this new instrument with our partners from Germany and the Global Fund. The Debt2Health initiative Bike taxi in Jakarta, Indonesida. From Wikimedia allows us to turn debt into new resources for Commons/Jonathan McIntosh. health in Indonesia,” said Dr. Rahmat Waluyanto, Director General of Debt Management, Ministry of Finance-RI. “We hope other creditor countries will join this initiative and offer Debt2Health agreements to Indonesia and other countries struggling with high disease burden and high levels of debt service.”
HIV/AIDS, tuberculosis and malaria remain public health threats in Indonesia, with approximately 170,000 people living with HIV. Indonesia is the country with the highest burden of tuberculosis in South East Asia with 150,000 people dying of tuberculosis every year. Close to 100 million Indonesians also live in areas susceptible to malaria. To date, the Global Fund has approved funding for six programs fighting HIV/AIDS, tuberculosis and malaria worth almost US$ 200 million. Of this amount, approximately US$108 million has already been disbursed to the country.
Germany was the first creditor country to offer Indonesia debt swap arrangements thereby facilitating a substantial reduction of the debt burden on Indonesian society. Six debt swap agreements between the Government of Indonesia and the Federal Republic of Germany have so far been implemented with a total sum of €143.56 million, including Debt2Health.
“Debt2Health is a win-win situation for Indonesia, Germany and the Global Fund: Indonesia gets more investments in health, the Global Fund increases predictability for its work and Germany contributes its share to the global fight against AIDS, tuberculosis and malaria,” said Baron Paul von Maltzahn, the Ambassador of Germany. “I am proud that Indonesia and Germany are pioneers in this new initiative which testifies to the good relations between our countries.”
The Echo Foundation 128 “One by One by One……..” “Debt2Health goes beyond traditional financing for development,” said Dr Michel Kazatchkine, Executive Director of the Global Fund. “It combines the well known instrument of debt swaps with the tested and proven disbursement mechanisms of the Global Fund to deliver high quality health care and prevention to people in need through programmes fully owned by Indonesia.”
The idea behind Debt2Health is to apply the well-established instrument of debt swaps to financing public health programs using the performance-based systems of the Global Fund. Debt2Health invites creditors to write off a portion of the debt owed them on the condition that the beneficiary countries invest an agreed-upon amount in local programs approved by the Global Fund. Debt conversion enables poor countries to devote more of their own resources to fighting HIV/AIDS, TB, and malaria, including essential health systems strengthening.
The Echo Foundation 129 “One by One by One……..” Chapter Three Discussion Questions
1. In what ways can community health workers improve a community’s living conditions?
2. Why is tuberculosis (TB) a problem in prisons? Why is this a problem for society?
3. Why do drug patents place a barrier to equitable healthcare?
4. What incentives do pharmaceutical companies have to lower their prices?
5. How do governments and organizations manage the costs for healthcare?
6. Why might user fees block access to healthcare?
7. In addition to health clinics, where else might user fees be applied?
8. Why is the development of new testing tools for TB important in developing countries?
9. Why is Plumpynut so revolutionary in combating malnutrition in developing countries?
10. In addition to raising the standard of living for women, what other areas should be considered in order to make PEPFAR funds more effective?
11. Why do low-income countries develop debt?
12. How is a country’s debt a burden on their healthcare services?
13. (See “Debt Swap Initiative Kicks Off in Indonesia” p. 128.)What incentives does Germany have to forgive Indonesia’s debt? Why should other nations forgive the debt in other developing countries?
14. Are global initiatives or local initiatives more effective in addressing healthcare problems? Why?
15. What are the components of effective healthcare initiatives?
16. What role can drug companies have in these initiatives?
The Echo Foundation 130 “One by One by One……..” IV. Delivering Healthcare in the West
aedics. aedics.
p
rom Beacon Ortho Beacon rom
F
St. Marys Hospital, Rochester, MN. Shared picture. AIDS Walk 2008 in New York City. From AIDS Walk New York/Jamie Clyde.
1. Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
2. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.
-Article 25, UN Declaration of Human Rights
Nearly one in five U.S. adults – more than 40 million people – report they do not have adequate access to the health care they need. (CDC, 2007)
The Echo Foundation “One by One by One……..” The Health Care Crisis
From The Washington Times Mar. 18, 2007 By Alex Gerber, M.D., Special to The Times
Modern medicine has probably done more to mitigate the misery and suffering that plague mankind than all the political ideologies, economic theories and religious persuasions combined.
The triumphs of modern medicine, however, are marred by the failure of health-care socioeconomics to keep pace with the brilliant advances of medical science and technology. The soaring costs of health care and the millions of medically uninsured Americans are stark testimonies of this truism.
Health-care costs are rising the fastest in history. Since 2000, private, employer-based insurance premiums have risen 4 times faster than wages. Total health-care spending has reached $1.9 trillion annually, 16 percent of the national gross domestic product (GDP), almost twice the ratio of the other industrialized nations and projected to climb to $4 trillion, 20 percent of the GDP, by 2015.
We can no longer ignore the dire consequences of the increasing health-care costs. Federal Reserve Board Chairman Ben Bernanke has warned us a fiscal crisis looms due to these unsustainable costs and “the U.S. economy could be seriously weakened, with future generations bearing the costs.” This admonition was first raised by George Washington’s 1796 Farewell Address when he impugned “ungenerously throwing upon posterity the burden which we ourselves ought to bear.”
Also hovering like dark clouds over our health-care system are 47 million medically uninsured Americans having risen 5 million since President Bush assumed office. That the uninsured have poorer medical outcomes has been well documented. Indeed, there are wards in our nation’s capital where health statistics are akin to those of Third World countries. The National Institute of Medicine has reported that 18,000 Americans die yearly for lack of health insurance, and our economy loses $60 billion to $ 130 billion per year due to poor health and early death. Federal Reserve Chairman Ben Bernanke. From Reuters/Jim Bourg.
The problem of runaway health costs and huge numbers of medically uninsured is related to the unanticipated nature of accidents and disease. The answer to preventing a medical calamity from becoming a financial catastrophe is budgeting in advance through insurance as we do for a possible house fire or auto accident.
The Echo Foundation 132 “One by One by One……..” But there are modifying factors with health insurance, revolving around society’s decision that health care, unlike owning a home or an auto, is a fundamental right. Thus, health problems beyond an individual’s control diabetes, congenital birth defects, being hit by a drunk driver should be insured by the community’s pooling of resources (not unlike the collective responsibility civilized societies assume for allaying the costs of natural disasters like hurricanes or floods). Since Otto von Bismarck introduced this concept in Germany more than a century ago, all modern industrial nations, except the world’s richest, have come to this conclusion.
The reason for this American anachronism is buried in history. During World War II, the War Labor Board froze wages and workers were in short supply. To lure them, employers picked up the tab for complete health insurance. National health-care costs in those days totaled only $40 billion yearly less than 5 percent of the Federal GDP. Due to the influence of its well-paid lobbyists in Washington, the private insurance industry has maintained its dominance of health insurance to this day.
Many health-care insurers are more interested in the bottom line than in the public’s health. The obvious way to increase profits is to decrease benefits by excluding poor health risks from insurance programs. This adverse selection of “cherry picking” plus the 10 percent to 30 percent overhead of marketing, advertising, stockholder dividends and huge executive salaries none of which cures a single patient is largely responsible for health-care costs that have “broken” our health-care system.
More than 40 million Americans are The answer to our outmoded, multipayer, profit-oriented completely uninsured. From BBC News/Getty Images. health-care industry is its replacement by a nonprofit, single-payer government agency. In short, universal health insurance (UHI) through Medicare for our entire population. President Clinton attempted to reform our health-care system along these lines but could not compete with the insurance industry’s $19 million, Harry and Louise TV blitz that conned the public and Congress into believing UHI was “socialized medicine.”
In fact, our country already has UHI workman’s compensation, which is the law in all 50 states. Society mandates health insurance for breadwinners who are injured on the job but not if they suffer the same injury while driving home from work. Why should a 5 o’clock whistle determine whether medical expenses are covered?
In this regard, UHI will not be as costly as popularly assumed perhaps one-tenth the eventual $2 trillion cost of the Iraq war. The uninsured are not all dying on the streets. The majority are obviously receiving care, admittedly delayed, somewhere emergency rooms, public hospitals or uncompensated care at private hospitals and clinics with a “cost shift” to the insured. We thus already largely pay for the care of the uninsured.
The Echo Foundation 133 “One by One by One……..” The model for a UHI program could well be the Canadian UHI health care system, with modifications, which boasts a quality of care equal to ours at far lower cost. Indeed more personnel are needed to administer Blue Cross in Massachusetts than to administer the entire health care system in Canada.
It was not always so. In 1971, the ratio of total health care costs to GDP was 7.1 percent in Canada and 7.6 percent in the United States. With the adoption of its single-payer health care system 25 years ago, Canada’s ratio rose to 9.6 percent in 2006 while ours has almost doubled to 16 percent.
Briefly, Canada’s health-care system provides one standard of care for the entire population, rich and poor alike, under a tax-funded plan. There are no additional expenses (deductibles or co- payments) at the time of treatment.
The superiority of Canada’s health-care system was perhaps best expressed by a recent Harris Interactive poll among the leading industrial societies that evaluated patient satisfaction with their health-care system. Canada ranked first and the United States last. An ABC News poll found that, by a 2-to-1 margin, Americans prefer a switch to Canada’s health-care system.
We should heed the voice of the people.
Alex Gerber, M.D., a clinical professor of surgery, emeritus, at the University of Southern California, is a former health-care consultant to the White House and the U.S. Department of Health and Human Services.
The Echo Foundation 134 “One by One by One……..” Health Care Crisis: Number of US Uninsured Soars, Along With Big Pharma Profits
From IPS News Agency Apr. 6, 2007 By Adrianne Appel
BOSTON—The U.S. is said to offer gold-standard health care, but as the most expensive health system in the world, some here say that only people with a pot of gold can get that care. Drug prices, health insurance, doctor visits and hospital stays are too expensive for many people to afford, while insurance and drug company profits continue to climb.
The nation is entering a health care crisis, many leaders and experts say. An estimated 46 million people do not have health insurance because they cannot afford it, and the U.S. has one of the poorest health profiles of the developed world.
Meanwhile, in 2005, pharmaceutical giant Johnson and Johnson earned profits of 10 billion dollars and Pfizer had profits of eight billion dollars, according to Fortune Magazine.
Health care is bankrupting even well-to-do U.S. citizens, especially people who have the misfortune of becoming seriously ill.
“The reason our health system is so crazy is we treat health care as a commodity. That really doesn’t work. Most countries see it as part of their job to take care of their people,” Meizhu Lui, executive director of United for a Fair Economy, told IPS.
The U.S. system is mostly privatised, which means that individuals alone or through their employers must buy their health care and health insurance on the open market. The government provides subsidised health care for the elderly and some of the poor and disabled.
Prices of many health services have soared in recent years and today individuals and the government spend 2.3 trillion dollars annually to purchase health insurance, doctor visits, medicines, hospital stays and special tests, according to Families USA, a health advocacy group.
“Our health care is in a car that is accelerating toward a cliff,” Alan Sager, co-director of the Health Reform Project at Boston University, told IPS.
The U.S. has a high rate of untreated diabetes and high blood pressure, which fall disproportionately on African Americans, Lui said.
“Unless you’re extremely wealthy it’s almost impossible to buy insurance. I’m in my fifties and it would cost me 6,000 dollars a year, and for a family it costs 12,000 dollars,” Steffie Woolhandler, an associate professor of medicine at Harvard University, told IPS.
The U.S. system today has created strange incentives, so that high-tech care is abundant for those who can pay for it while preventive care, like annual check ups, is not encouraged, Woolhandler said.
The Echo Foundation 135 “One by One by One……..” “It is remarkable we spend so much and yet fail to cover so many people,” Sager said.
Health care companies wield tremendous political power, Lui noted.
For years, health activists, organisations of the elderly and labour unions have tried to convince Congress to allow citizens and the government to negotiate bulk prices for drugs or to purchase them from Canada, rather than paying full price on the open U.S. market. Congress has not The US spends more on healthcare than budged on this or other health care reform issues. any other country. From BBC News.
Behind the scenes, drug companies, hospitals, insurance companies and doctor organisations spent 400 million dollars in 2005 and 2006 lobbying Congress and federal candidates to enact policies the companies favour, according to Opensecrets, an organisation which tracks the records.
“Our government, instead of helping people, is being held hostage by these profit-making companies,” Lui told IPS.
According to the Centre for Public Integrity, drug companies recently lobbied against strong safety regulations, and successfully lobbied to include patent protection in trade negotiations with other nations.
Drug companies also benefit because they receive favourable tax treatment from the U.S. government, Bob McIntyre, director of Citizens for Tax Justice, told IPS.
“They get to write off their purchases of equipment. They get a big break for anything considered research,” McIntyre said.
All this adds up to big profits for the companies involved. In 2005, the drug companies Proctor and Gamble, Merck, Amgen, Abbot and insurer UnitedHealth Group were among the 50 most profitable Fortune 500 companies in the U.S., according to Fortune Magazine.
Many large drug companies richly reward their chief executive officers with salaries and bonuses. Johnson and Johnson’s CEO received salary and bonuses in 2006 of 28 million dollars, according to Dow Jones. And Merck CEO Richard Clark received 10 million dollars in compensation, according to AFL-CIO Corpwatch.
When former Pfizer CEO Henry McKinnell left the company in 2006, he was given pension, stock and other benefits worth 180 million dollars, according to AFL-CIO Corpwatch.
But CEO William McGuire, of UnitedHealth Group, a health Henry McKinnell, former CEO insurance company, stands alone. His annual salary in 2005 was of Pfizer USA. From The 124 million dollars and he has been provided stock options worth AP/Laurent Gillieron.
The Echo Foundation 136 “One by One by One……..” more than 1.7 billion dollars, according to Forbes.com. As part of his retirement package, he and his spouse will receive free health care for as long as they live, according to AFL-CIO Corpwatch.
This is not the case for the average U.S. family, Woolhandler said. If a parent becomes too ill to work, they may lose their salary and be unable to pay their health insurance. “We found that three-quarters of people bankrupted by illness had insurance at the beginning,” Woolhandler said.
People who have an existing illness, like asthma, are charged double the price for insurance or may be refused altogether, said Woolhandler, who founded Physicians for a National Health Programme, which wants the U.S. to switch to a government-run health care system, as in Canada.
A number of companies made headlines recently by trying to boost their profits through illegal drug marketing schemes, cheating on their taxes or skimping on safety, according to Peter Rost, former vice president of marketing for Pfizer and author of the book “Whistleblower”.
Pfizer was recently fined 430 million dollars for attempting to defraud a government programme. Schering Plough paid a 500-million-dollar fine for manufacturing violations, and 345 million dollars for improper marketing of Claritin, an allergy drug, Rost says.
The U.S. tax authority, the Internal Revenue Service, has demanded that drug company GlaxoSmithKline pay 7.8 billion dollars in back taxes while Merck may be facing two billion dollars in back tax payments.
The Echo Foundation 137 “One by One by One……..” Free Clinic Helps People Who Need It Most
From CBS News June 11, 2008 By Seth Doane
I’ve wanted to do a story on free clinics for the uninsured since I visited one such clinic this winter in Greenville, Miss., along the Mississippi River Delta. There I found a nurse practitioner who was working as hard as she could to serve a population that had very limited access to medical care. In the few hours that I visited this clinic, we met folks who hadn’t seen a doctor in years because they couldn’t afford to.
I found many of the same stories in Flint, Mich., at the Genesee County Free Medical Clinic. The clinic treats only the uninsured and is funded entirely through fundraising and the support of several local hospitals. More than 60 nurses and 60 doctors volunteer their time to help.
I learned about the clinic after reading a couple of local stories about a volunteer there, Dr. Samuel Dismond, who recently won a community service award for his work. Dismond is a thoughtful, gentle man who told me that it’s “rejuvenating” to volunteer at the clinic. Though he also said that “it can be a frustration to me, as a healer, [to see] so many people we’re not able to help and not help adequately.”
There are plenty of people in Flint that do, indeed, need help. Home to General Motors, there have been a number of layoffs as factories have been closed down and shifts have been cut. When we were at the From CBS News. clinic, Dale Willis who had just been permanently laid off from his job at an auto-parts supplier came in for the first time. Willis was clearly shaken by the loss of his job and worried that it would be hard to find another one at his stage in life. Willis told me that he’d even consider taking a job as a janitor if he needed to. “If you’d asked me at 21 what I’d be like at 51, I’d say, in a lot better situation than I am now!” Dale said.
Susan (didn’t want to give her last name) was at the clinic too. She saw a flyer for the free clinic in the trailer park where she lives. Though she’d just started a job at WalMart she didn’t have medical insurance yet. “It’s scary not having medical because if anything ever really seriously happened to me, I don’t know how I’d take care of it,” Susan told me. That fear was echoed among everyone we spoke with, and the volunteers at Genesee County Free Medical Clinic clearly know they’re filling a need.
Kimberlee Maloney, a registered nurse who lost her job and insurance, may have summed it up best when she said, “It’s devastating because every day you wake up and think, ‘Today I hope there’s nothing wrong.’”
The Echo Foundation 138 “One by One by One……..” When Your Local Pharmacist Is In Mexico
From CBS News Mar. 3, 2008 By Byron Pitts
Rosie Perez is a U.S. citizen, born and raised in Texas. So why is her local pharmacist in Mexico?
“It’s degrading. This box would cost me $100.99 in the U.S.,” she tells CBS News national correspondent Byron Pitts. “I am getting it from the Mexican side for $27.”
There are similar stories from other U.S. citizens who cross the Texas border into Mexico for their prescriptions, doctor visits, dental care and even surgery. People from as far away as Iowa, Minnesota and Illinois.
“The healthcare system in this country is a travesty,” says Gana Jones, a truck driver originally from Dallas. Like 47 million Americans, she has no health insurance. Her choice? To live within driving distance of Mexico.
“I can come over here, I can get an X-ray for $25. I can buy my prescriptions for about 60 percent less than I would have to pay in the U.S.,” she tells Pitts.
For Perez, the dark reality is health care in Mexico is her only affordable choice. A diabetic, she lost her job at a windshield wiper plant six months ago. Few if any employers in Brownsville are hiring full time a 46-year-old with a pre-existing medical condition.
Her doctor of four years will no longer see her. “Suddenly, you lose your job, your health card and then they don’t even know you,” she says tearfully.
From Perez’s House in Brownsville, Texas, it’s a 20- minute drive across the border into Matamoros, Mexico, to pharmacies, medical facilities and savings. Her doctor’s visit in the United States cost her $125. In Mexico: $3.
We asked the Clinton and Obama campaigns how their From CBS News. health care plans would help someone like Rosie.
Under Clinton’s plan, a person like Perez who has virtually no income would receive government-subsidized health insurance but she would still be required to pay a small co-pay. And Clinton’s plan could lower Perez’s prescription drugs by up to 40 percent by allowing the re-importation of prescription drugs from foreign countries.
The Echo Foundation 139 “One by One by One……..” Under Obama’s plan, he’d lower the federal poverty line which would make Perez eligible to receive Medicaid with a zero or small co-pay. Last year, Perez made $12,000. Also, Obama’s plan would allow the government to negotiate with drug companies for a lower price which would help reduce Perez’s prescription cost.
Obama’s plan also supports re-importation of drugs to help rein in rising costs, reports Pitts. But critics caution neither is a silver bullet.
“If you’re mandating or obliging people to purchase a policy that they cannot afford, it’s not going to work in an area like this,” says Jose Pagan, an economics professor at the University of Texas-Pan American. “People will always have the option of going to Mexico to get healthcare.”
“People” like Rosie Perez.
“I can get health insurance from a private agency which will cost me $389 a month,” she says. “I would say I bring in about $400 a month working now.”
The Echo Foundation 140 “One by One by One……..” France’s Model Health Care for New Mothers
From NPR July 10, 2008 By Joseph Shapiro
Mary Lou Sarazin went to Paris to teach. When the job ended, she was newly married to a French husband and pregnant. Her visa had expired, however, and she couldn’t renew it right away, so she returned to New York a little over a year ago to finish graduate school and have the baby. Sarazin, 34, has since received health care in both France and the United States. Her experience has given her a firsthand look into why France has earned a reputation for being a good place to be pregnant and have a child.
In New York, pregnant and unable to find work, Sarazin couldn’t find health insurance that she Mary Lou Sarazin holds her baby, Ludivine, in could afford. Eventually, she did get limited Paris. From NPR/Anna Vigran. coverage through New York Medicaid, the state program for the poor and uninsured, but it only covered her prenatal and hospital care. Once the baby was born, she would be uninsured again. “I just felt like when I was in New York, it was always stress, stress, stress,” she says. “I just didn’t like the care I was receiving. And I didn’t want to stress out about something I shouldn’t have to stress out, not at the time of my pregnancy.”
France’s Model
At the same time, a good friend back in Paris was also pregnant. She kept telling Sarazin about her easy access to prenatal care, the nurses who made home visits and how she’d already gone on paid job leave, months before her baby was due. So Sarazin headed back to Paris to have her baby.
“In France, it just seems that it’s so family oriented,” she says. “A pregnant woman is seen and regarded as a special moment.”
On a cheery spring day, Sarazin finds a park bench in the sun with Ludivine, her daughter, who was born in November. Ludivine has curious brown eyes. She’s bundled in a knitted pink sweater and matching booties made by her French grandmother. Mother and daughter get approving smiles from people who pass by. “One thing I love about here is, once you have a baby, people are the nicest,” Sarazin says. “They’re just incredibly, incredibly kind.”
The Echo Foundation 141 “One by One by One……..” In France, she has found affordable health care that’s easy to get and easy to use. Medications are provided free or at a deep discount by the national health insurance system. National insurance also reimburses 70 percent of the cost of a visit to a doctor. The rest gets picked up by supplemental insurance, which Sarazin and her husband, a municipal bus driver, purchase for a small monthly fee. Almost 90 percent of people in France have supplemental insurance, and it’s often paid in full or in part by one’s employer.
Sarazin says she misses the United States. However, if she and her husband have more children, she says they’ll stay in France.
Complications at Home
Tanya Blumstein is another American mother who experienced health care when she was pregnant in both the United States and in France.
On a Friday afternoon, she and her husband, Tomas Lacronique, pick up their 14-month-old daughter, Ella, at the home of a nearby day care provider. Ella puts out her arms and squeals in delight. The private day care is heavily subsidized by the French government.
Tanya moved to France after college to work in the film industry. After she met Tomas, his company sent him to work in New Jersey, so they traveled back and forth between Paris and New York. When Tanya got pregnant, she moved to Manhattan to be with him.
In the United States, Tomas had insurance from Blue Cross Blue Shield. Tanya couldn’t get on his policy, however, because they weren’t yet married. She tried to buy health insurance for herself, but every American insurer turned her down. The reason: She was pregnant. Tanya Blumstein and Tomas Lacronique play with their daughter, Ella. From NPR/Anna Vigran. “They said, ‘We don’t insure a house on fire,’” she says, remembering the unpleasant euphemisms insurance agents used to explain their rejections.” I had a ‘pre-existing condition,’ which was pregnancy. I just couldn’t believe it.”
Blumstein and Lacronique went to City Hall in New York and got married, and then she was added to her husband’s insurance. But even then, they found the American system daunting. There were so many decisions to make, so much terminology to figure out and so much care to coordinate. Their insurance covered major things, such as the labor and delivery, but not totally. And other care, like hiring a midwife, was considered “out of network,” which meant the couple would have to pay for a lot of it themselves.
“I have my notes here,” Tanya says in the family’s walk-up apartment in Paris, as she pulls out a stack of papers. “I was trying to navigate all this. And so, my questions: I was like, wait, what is
The Echo Foundation 142 “One by One by One……..” deductible out of network? What is co-insurance? Will they pay at New York rate if submitted to local, because it was a New Jersey thing? And first visit $3,000, follow-up $175. Out-of-pocket L and D package is $5,000. And then this midwife is only out of network—$7,500 fee for being out of network, plus deductible.”
Tanya and Tomas loved living in New York and being in a country where there was so much choice and where it was so easy to be a consumer—except, as they found out, when it comes to health care. “Everything is so simple when want to get a cab, or rent a car, or take out, eat fast food,” Tomas says. “But once it gets to serious issues—your health—then it gets hellish.”
Late in her pregnancy, Tanya left Tomas in New York and returned to Paris to have her baby. Tomas later changed jobs to be with his family in France.
The Best in the World
Tanya says health care in France is a lot easier to use. There is a neighborhood health clinic, where she can show up with the baby anytime, with or without an appointment. She gets letters from a local health authority telling her what benefits are available and when she should come to a clinic with her daughter for her regular checkups.
When Ella got a stomach flu earlier this year, a doctor made a house call at 3 a.m. on a Sunday. It was paid for entirely by health insurance.
This is the kind of comprehensive coverage that gets France’s health care rated the best in the world by the World Health Organization. It’s also why France has some of the world’s lowest infant mortality rates and some of the highest birth rates in Europe.
To the French, all of this care is intended to help parents succeed and to make sure children grow up healthy, says Victor Rodwin, who studies the French health care system.
“When you’re a new mother, you’re very well taken Nurse Nadege Heurtebise visits a young couple care of in France,” says Rodwin, a professor of health and their two-week old baby in Chartres. From policy at New York University, who is also affiliated NPR/Joseph Shapiro. with the International Longevity Center. “They take very good care of their mothers when they’re pregnant. There’s, of course, no problem of uninsured mothers. They get good prenatal care, and they have house visitors—nurses who come to the house and help the first week.”
House Calls
Those visiting nurses are key to making the system work. They’re sponsored by their local Maternal and Infant Protection Service and are sent to make home visits to pregnant women and to parents and their babies.
The Echo Foundation 143 “One by One by One……..” Nadege Heurtebise is one of those nurses in the city of Chartres. She wears black Chuck Taylor sneakers and drives a small car to the brightly painted apartment of Isabelle and Yannick Fourcade. Their son Clement was born two weeks ago.
The nurse asks how the baby sleeps and eats. She tells the parents about vaccination schedules and well-baby visits, and about their options for subsidized day care. She weighs the baby and then watches the mother breast-feed to see if there are any problems. The visit takes an hour, which is about average for a home visit. It costs the young parents nothing. There is not even paperwork to sign.
On the drive back to her office, Heurtebise explains that there is an advantage to going to a family’s home instead of waiting for the family to come to the doctor. In the home, the nurse can spot a problem before it becomes dangerous, such as a child who is not eating or parents who are doing something incorrectly. “I never tell them what they’re doing is wrong,” Heurtebise says. “I just tell them something else is possible.” For almost all of her home visits, though, her job is simply to reassure new parents that they are indeed doing a good job.
Everything but the Laundry
One thing nurses do not do is the family’s laundry, contrary to what some Americans may think after watching the Michael Moore documentary Sicko. The movie contains a memorable scene where a state worker goes to a new mother’s home to do her wash. Back at Heurtebise’s office, her boss, Dr. Marie-Paule Martin, says she saw Sicko, too. “I had a great laugh,” she says with a smile. “With Michael Moore, it’s very caricature.”
A state-paid housekeeper will do a mother’s laundry only in certain situations, she says, such as when there is a medical complication after the birth. Or, in situations where there is reason to think a mother is neglecting her children, workers may go in to try to stabilize the family.
Even without laundry service, French health care comes at a high cost. There are questions about how long France can sustain it. The health system ran a nearly $9 billion deficit last year. The government of President Nicolas Sarkozy has since proposed that people should pay more of the cost for their own care.
Nonetheless, even under pressure to put the system back From the Internet Movie Database. in the black, the basic benefits to mothers and their children remain the same.
The Echo Foundation 144 “One by One by One……..” V. Election 2008
Microsoft Office photo.
From BarackObama.com. From JohnMcCain.com.
“We now face an opportunity—and an “We want a system of healthcare in which obligation—to turn the page on the failed everyone can afford and acquire the treatment politics of yesterday's healthcare debates. My and preventative care they need, and the peace plan begins by covering every American. If you of mind that comes with knowing they are already have health insurance, the only thing covered. Healthcare in America should be that will change for you under this plan is the affordable by all, not just the wealthy. It amount of money you will spend on premiums. should be available to all, and not limited by That will be less. If you are one of the 45 where you work or how much you make. It million Americans who don't have health should be fair to all; providing help where the insurance, you will have it after this plan need is greatest, and protecting Americans becomes law.” from corporate abuses.” -Barack Obama -John McCain
The Echo Foundation “One by One by One……..”
How do the Candidates Fare on Healthcare Provision?
Barack Obama (D) vs. John McCain (R) for President One……..” y Elizabeth Dole (R) vs. Kay Hagan* (D) for U.S. Senator from North Carolina**
One b
y From Project Vote Smart
Date Bill Proposal Obama’s McCain’s Dole’s How the Bill Passed “One b Vote Vote Vote Senate voted in Senate?
7/16/2008 HR • To authorize $48 billion in aid to Abstained Abstained Yes 80-16 Yes 5501*** combat HIV/AIDS, malaria, and tuberculosis from 2009 through 2013. 3/14/2008 S Amdt • To support legalizing the importation Yes Abstained No 73-23 Yes 4299 of prescription drugs [into the US] from other developed countries. 3/14/2008 S. Amdt • To redefine a “targeted low-income No Yes Yes 46-52 No 4233 child” who is eligible for child health assistance under the State Children’s Health Insurance Program (SCHIP) as “an individual under age 19, including the period from conception to birth.” 2/26/2008 S. 1200 • To fund and expand programs related Abstained— Abstained Yes 83-10 Yes to Native American healthcare. but was co- sponsor of bill 146
8/2/2007 HR 976 • To reauthorize and expand the State Yes No No 68-31 Yes n Children’s Health Insurance Program (CHIP) through 2012.
*Dole’s opponent, Kay Hagan, does not have U.S. Senate voting records, because she has yet to be elected as a U.S. Senator. **Richard Burr, the Junior U.S. Senator from North Carolina, is not up for reelection until 2010. ***This is a substituted bill—the language of the original bill [see next page] was changed. The Echo Foundatio
How do the Candidates Fare on Healthcare Provision? Sue Myrick (R) vs. Harry Taylor* (D) for U.S. Representative [9th Congressional District] th
Melvin Watt (D) vs. Tyrus Cobb* (R) for U.S. Representative [12 Congressional District] One……..” y
From Project Vote Smart One b
y Date ID Proposal Myrick’s Watt’s How the Bill Passed
Vote Vote House voted in House? “One b
4/2/2008 HR 5501 • To authorize $50 billion in aid to combat HIV/AIDS, No Yes 308-116 Yes malaria, and tuberculosis from 2009 through 2013. 8/1/2007 HR 3162 • To reauthorize and expand the State Children’s Health No Yes 225-204 Yes Insurance Program (CHIP) through 2012. 1/12/2007 HR 4 • To require the Secretary of Health and Human Services No Yes 225-170 Yes to negotiate lower drug prices for Medicare part D [Part D pays for drugs for Medicare recipients]. 3/24/2004 HR 3873 • To ensure that the $16 billion taxpayers invest for Yes Yes 419-5 Yes nutrition programs targeting under-privileged children and families would effectively meet their nutritional needs as well as educate all children in schools. 5/1/2003 HR 1298 • To establish a five-year program, authorizing $3 billion Yes Yes 375-41 Yes each year to prevent and treat HIV, AIDS, tuberculosis, and malaria in highly infected countries. 7/13/2000 HR 4811 • To fully fund the Bush administration’s request of $225 No Yes 216-211 Yes million for debt relief for the world’s poorest countries.
7/13/2000 HR 4811 • To transfer $40 million from foreign military and anti- Yes Yes 267-156 Yes 147 narcotics assistance to the Agency for International n Development—Child Survival and Disease Programs Fund, specifically for the prevention and treatment of HIV/AIDS.
*Myrick’s and Watt’s opponents, Taylor and Cobb respectively, do not have U.S. House of Representative voting records, because they have yet to be elected as U.S. Representatives. The Echo Foundatio
Political Courage (Issue) Tests
One……..” y From Project Vote Smart
One b Administered by Project Vote Smart and sent to Presidential, Congressional, and gubernatorial candidates, the Political Courage Test y asks candidates about the issues that they will support if (re)elected. Of our candidates of interest, only Elizabeth Dole, Sue Myrick, and Harry Taylor have submitted the Political Courage Test.* “One b *Neither Beverly Perdue nor Patrick McCrory, North Carolina’s candidates for governor, has submitted Political Courage Tests. Also, because neither candidate was previously in a voting office, voting records are not available.
Elizabeth Dole a) On Healthcare Indicate which principles you support (if any) regarding health. a) Implement a universal healthcare program to guarantee coverage to all Americans, regardless of
income. X b) Expand eligibility for tax-free medical savings accounts. c) Allow the importation of prescription drugs into the United States. X d) Support expanding prescription drug coverage under Medicare. X e) Offer tax credits to individuals and small businesses to offset the cost of insurance coverage. X f) Support expanding child healthcare programs. 148
g) Providing healthcare is not a responsibility of the federal government. n h) Other or expanded principles I supported the expansion of Medicare to include a prescription drug benefit for seniors. I will support allowing drug re-importation from other countries only if it includes sufficient safety measures to protect American consumers. b) On International Aid Indicate which principles you support (if any) regarding international aid. The Echo Foundatio
a) Support the United States granting aid to countries when extraordinary circumstances cause disaster X and threaten civilian lives. b) Support the United States granting aid to countries when it is in the security interests of the United X
States. One……..” y c) Eliminate United States aid for any nation with documented human rights abuses. d) Aid granted by the United States should be scaled back and eventually eliminated. One b
e) Other or expanded principles y Sue Myrick a) On Healthcare “One b Indicate which principles you support (if any) regarding health. a) Implement a universal healthcare program to guarantee coverage to all Americans, regardless of
income. X b) Expand eligibility for tax-free medical savings accounts. c) Allow the importation of prescription drugs into the United States. X d) Support expanding prescription drug coverage under Medicare. X e) Offer tax credits to individuals and small businesses to offset the cost of insurance coverage. f) Support expanding child healthcare programs. g) Providing healthcare is not a responsibility of the federal government. h) Other or expanded principles I strongly support the creation of small business health insurance pools. b) On International Aid Indicate which principles you support (if any) regarding international aid. 149 a) Support the United States granting aid to countries when extraordinary circumstances cause disaster n X and threaten civilian lives. b) Support the United States granting aid to countries when it is in the security interests of the United X States. X c) Eliminate United States aid for any nation with documented human rights abuses. d) Aid granted by the United States should be scaled back and eventually eliminated. The Echo Foundatio
e) Other or expanded principles Harry Taylor a) On Healthcare One……..”
Indicate which principles you support (if any) regarding health. y a) Implement a universal healthcare program to guarantee coverage to all Americans, regardless of X income. One b X b) Expand eligibility for tax-free medical savings accounts. y X c) Allow the importation of prescription drugs into the United States.
d) Support expanding prescription drug coverage under Medicare. “One b e) Offer tax credits to individuals and small businesses to offset the cost of insurance coverage. X f) Support expanding child healthcare programs. g) Providing healthcare is not a responsibility of the federal government. h) Other or expanded principles Re: question ‘e’ above...we should be working to get employers out of the business of providing health insurance coverage b) On International Aid Indicate which principles you support (if any) regarding international aid. a) Support the United States granting aid to countries when extraordinary circumstances cause disaster X and threaten civilian lives. b) Support the United States granting aid to countries when it is in the security interests of the United X States. X c) Eliminate United States aid for any nation with documented human rights abuses. 150
d) Aid granted by the United States should be scaled back and eventually eliminated. n e) Other or expanded principles
The Echo Foundatio
Straight Talk on Health System Reform John McCain
From the John McCain for President Website
A “Call to Action”
In Florida, John McCain outlined his plan for health care reform. John McCain believes we can and must provide access to health care for every American.
Americans are worried about health care costs. The problems with health care are well known: it is too expensive and 47 million people living in the United States lack health insurance.
John McCain’s Vision for Health Care Reform
John McCain believes the key to health care reform is to restore control to the patients themselves. We want a system of health care in which everyone can afford and acquire the treatment and preventative care they need. Health care should be available to all and not limited by where you work or how much you make. Families should be in charge of their health care dollars and have more control over care.
Making Health Insurance Innovative, Portable and Affordable
John McCain will reform health care making it easier for individuals and families to obtain insurance. An important part of his plan is to use competition to improve the quality of health insurance with greater variety to match people’s needs, lower prices, and portability. Families should be able to purchase health insurance nationwide, across state lines.
John McCain will reform the tax code to offer more choices beyond employer-based health insurance coverage. While still having the option of employer-based coverage, every family will also have the option of receiving a direct refundable tax credit—effectively cash—of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider. Those obtaining innovative insurance that costs less than the credit can deposit the remainder in expanded Health Savings Accounts.
John McCain proposes making insurance more portable. Americans need insurance that follows them from job to job. They want insurance that is still there if they retire early and does not change if they take a few years off to raise the kids.
John McCain will encourage and expand the benefits of health savings accounts (HSAs) For Families. When families are informed about medical choices, they are more capable of making
The Echo Foundation 151 “One by One by One……..” their own decisions and often decide against unnecessary options. Health Savings Accounts take an important step in the direction of putting families in charge of what they pay for.
A Specific Plan of Action: Ensuring Care for Higher Risk Patients
John McCain’s plan cares for the traditionally uninsurable. John McCain understands that those without prior group coverage and those with pre-existing conditions have the most difficulty on the individual market, and we need to make sure they get the high-quality coverage they need.
John McCain will work with states to establish a guaranteed access plan. As President, John McCain will work with governors to develop a best practice model that states can follow—a Guaranteed Access Plan or GAP—that would reflect the best experience of the states to ensure these patients have access to health coverage. One approach would establish a nonprofit corporation that would contract with insurers to cover patients who have been denied insurance and could join with other state plans to enlarge pools and lower overhead costs. There would be reasonable limits on premiums, and assistance would be available for Americans below a certain income level.
John McCain will promote proper incentives. John McCain will work with Congress, the governors, and industry to make sure this approach is funded adequately and has the right incentives to reduce costs such as disease management, individual case management, and health and wellness programs.
A Specific Plan of Action: Lowering Health Care Costs
John McCain proposes a number of initiatives that can lower health care costs. If we act today, we can lower health care costs for families through common-sense initiatives. Within a decade, health spending will comprise twenty percent of our economy. This is taking an increasing toll on America’s families and small businesses. Even Senators Clinton and Obama recognize the pressure skyrocketing health costs place on small business when they exempt small businesses from their employer mandate plans.
CHEAPER DRUGS: John McCain will look to bring greater competition to our drug markets through safe re-importation of drugs and faster introduction of generic drugs.
CHRONIC DISEASE: Chronic conditions account for three-quarters of the nation’s annual health care bill. By emphasizing prevention, early intervention, healthy habits, new treatment models, new public health infrastructure and the use of information technology, we can reduce health care costs. We should dedicate more federal research to caring and curing chronic disease.
COORDINATED CARE: Coordinated care—with providers collaborating to produce the best health care—offers better outcomes at lower cost. We should pay a single bill for high-quality disease care which will make every single provider accountable and responsive to the patients’ needs.
The Echo Foundation 152 “One by One by One……..”
GREATER ACCESS AND CONVENIENCE: Families place a high value on quickly getting simple care. Government should promote greater access through walk-in clinics in retail outlets. INFORMATION TECHNOLOGY: We should promote the rapid deployment of 21st century information systems and technology that allows doctors to practice across state lines.
MEDICAID AND MEDICARE: We must reform the payment systems in Medicaid and Medicare to compensate providers for diagnosis, prevention and care coordination. Medicaid and Medicare should not pay for preventable medical errors or mismanagement.
SMOKING: Most smokers would love to quit but find it hard to do so. Working with business and insurance companies to promote availability, we can improve lives and reduce chronic disease through smoking cessation programs.
STATE FLEXIBILITY: States should have the flexibility to experiment with alternative forms of access, coordinated payments per episode covered under Medicaid, use of private insurance in Medicaid, alternative insurance policies and different licensing schemes for providers.
TORT REFORM: We must pass medical liability reform that eliminates lawsuits directed at doctors who follow clinical guidelines and adhere to safety protocols. Every patient should have access to legal remedies in cases of bad medical practice but that should not be an invitation to endless, frivolous lawsuits.
TRANSPARENCY: We must make public more information on treatment options and doctor records, and require transparency regarding medical outcomes, quality of care, costs and prices. We must also facilitate the development of national standards for measuring and recording treatments and outcomes.
Confronting the Long-Term Challenge
John McCain Will Develop A Strategy For Meeting The Challenge Of A Population Needing Greater Long-Term Care. There have been a variety of state-based experiments such as Cash and Counseling or The Program of All-Inclusive Care for the Elderly (PACE) that are pioneering approaches for delivering care to people in a home setting. Seniors are given a monthly stipend which they can use to: hire workers and purchase care-related services and goods. They can get help managing their care by designating representatives, such as relatives or friends, to help make decisions. It also offers counseling and bookkeeping services to assist consumers in handling their programmatic responsibilities.
The Echo Foundation 153 “One by One by One……..” Position on Healthcare Barack Obama
From the U.S. Senate
The United States is one of the wealthiest nations in the world, yet more than 45 million Americans have no health insurance. Too many hard-working Americans cannot afford their medical bills, and thus, health-related issues are the number one cause for personal bankruptcy. Too many employers are finding it difficult to offer the coverage their employees need.
Promoting affordable, accessible, and high-quality health care was a priority for Barack Obama in the Illinois State Senate and is a priority for him in the United States Senate. He believes firmly that health care should be a right for everyone, not a privilege for the few.
Preserving and Improving Medicare and Medicaid
Medicare and Medicaid represent America’s commitment to take care of the elderly and the poor—some of our most vulnerable citizens. Senator Obama has voted to preserve and strengthen these programs at every opportunity. He has voted to restore funding to these programs and has voted against budgets that cut these programs.
Medicare
Some 42 million American seniors are served by Medicare, including 1.7 million in Illinois. Medicare is a promise we have made to our seniors, and along with Social Security, it is essential to a dignified and financially sound retirement. Cuts to Medicare will seriously harm those who have worked all their lives, paid into the system, and need medical care.
Senator Obama is concerned about the Medicare Part D Prescription Drug Program and its effect on our nation’s elderly and disabled. In particular, he is concerned about the difficulty encountered when enrolling and choosing among a large number of plans (more than 40 in Illinois); the restrictions on changing plan selection after enrollment; the prohibition against negotiating for the best drug price or discounts, and the high costs of the program for seniors.
Senator Obama is a cosponsor of the Medicare Informed Choice Act, which would have extended enrollment without penalty and allowed for a one-time plan change during the first year of the plan.
Medicaid
Medicaid is the nation’s health safety net. Over 53 million Americans of all ages, including 2 million Illinoisans, rely on Medicaid for their health care. As a member of the Senate’s Medicaid Working Group, Senator Obama will continue the fight to strengthen Medicaid, as well as help providers who care for large numbers of poor and uninsured patients.
The Echo Foundation 154 “One by One by One……..”
Improving Quality of Health Care
Senator Obama is pursuing legislative initiatives to help improve health care quality.
He helped draft and introduce the National MEDiC Act, which promotes patient safety initiatives, including early disclosure and compensation to patients injured by medical errors. He also introduced the Hospital Quality Report Card Act, which will use federal hospital quality reporting requirements to inform and assist patients and other consumers in making their health care decisions.
Senator Obama strongly believes that greater use of health information technology can contain costs and improve the efficiency of our health care system. He introduced the Federal Employees Health Benefits Program Efficiency Act, which would leverage the federal government’s purchasing power to encourage increased adoption of technology by participating health plans.
In 2005, Senator Obama spoke at the commencement of the University of Chicago’s Pritzker School of Medicine about the importance of health information technology.
Children’s Health
An estimated 8.7 million children in the U.S. are uninsured, and this figure represents an increase for the second year in a row. Health coverage is critically important for a healthy start in life, and this is particularly true now that the rate of many diseases in children—obesity, diabetes, and high blood pressure, to name a few—has started to rise dramatically. This nation can and must do more to protect and promote the health of children. To address this problem, Senator Obama has been a strong supporter of expanding the Children’s Health Insurance Program (CHIP) to cover more uninsured children.
HIV/AIDS
Promoting the prevention of HIV/AIDS domestically and abroad, as well as accelerating the research and development of treatments for the disease, is a priority of Senator Obama’s. With 8,000 AIDS-related deaths and 14,000 new infections every day, HIV/AIDS will likely become the third leading cause of death in the world.
While traveling in Africa in August of 2006, Senator Obama and his wife took a public HIV test in hopes of decreasing the stigma surrounding testing. Additionally, Senator Obama calls for an increase of at least $1 billion per year for the President’s Emergency Plan for AIDS Relief (PEPFAR) in order to expand our global AIDS efforts into Asia and the Middle East, enhance our work in Africa, and further address issues such as nutrition and prevention.
In Illinois, an estimated 40,000-42,000 individuals are living with HIV/AIDS. The Ryan White Care Act (RWCA) provides the majority of Federal support for those suffering from HIV/AIDS in our country. This legislation was reauthorized during the final hours of the 109th Congress, although changes in the epidemic—as well as insufficient funding—made it a difficult
The Echo Foundation 155 “One by One by One……..” reauthorization to tackle. Throughout the reauthorization process, Senator Obama worked closely with RWCA service providers, the Chicago Department of Public Health, and the Illinois Department of Public Health to analyze and find ways to improve the program for Illinois and for the nation. Senator Obama will continue to protect the multifaceted care upon which RWCA beneficiaries depend.
Over the last few years, it has become clear that women are rapidly becoming the new face of the AIDS epidemic, both here in the United States and around the world. We are faced with the sobering statistic that by the end of the day, another 7,000 women will have been infected with HIV. In the United States, the percentage of women diagnosed with AIDS has quadrupled over the last twenty years. In fact, AIDS is now the number one cause of death among African- American women aged 25-34.
In order to expedite the availability of preventive tools for women, Senator Obama is the lead Democratic sponsor of the Microbicide Development Act, which encourages scientific leadership on this issue and strengthens research and development programs at the National Institutes of Health, Centers for Disease Control, and the US Agency for International Development (USAID). The legislation would also establish a unit at the NIH specifically dedicated to microbicide research. Microbicides are a class of products currently under development that women could use to protect themselves from contracting HIV, even while conceiving children. When fully developed, experts predict that microbicides could stop 2.5 million infections over three years in women, men, and infants.
Avian Flu
Avian influenza—or bird flu—is a potentially grave health threat to the U.S. and other countries around the world. Senator Obama was one of the first members of Congress to speak out about the issue and push for greater funding to improve preparedness.
Starting in March 2005, he obtained $25 million for international efforts to combat the avian flu and called for an inter-agency task force to immediately address this issue. This funding is now being used to mitigate the effects of the pandemic in Southeast Asia.
Senator Obama introduced the Attacking Viral Influenza Across Nations Act, which calls for collaboration and cooperation at the state, national, and international level to ensure preparedness in the event of pandemic influenza. Such preparedness includes the procurement of antivirals, development of effective vaccines, and improvement of the public health infrastructure and medical surge capacity in hospitals.
Senator Obama also worked to push $7.9 billion through the Senate to help the U.S. prepare for the possibility of an avian flu pandemic.
The Echo Foundation 156 “One by One by One……..” Chapter Four and Five Discussion Questions
1. What challenges face the United States healthcare system today?
2. Is the government responsible for ensuring its citizens have access to healthcare? Why or why not?
3. Who holds the government accountable for providing healthcare?
4. How has healthcare become a commodity?
5. If you have no health insurance in the United States, how do you receive healthcare?
6. Why do people travel to Canada or Mexico to get prescription drugs? Why don’t they buy the drugs in the United States?
7. What is the purpose of a drug patent?
8. What role do pharmaceutical companies have in determining the cost of healthcare?
9. How does France’s healthcare system differ from the one in the United States?
10. Who might be opposed to a universal healthcare system? Why?
11. How does France finance universal healthcare?
12. What would be the benefits/costs to a universal healthcare system in the United States?
13. Does the United States already have in place systems of free healthcare?
14. Why are the healthcare costs in the United States soaring out of control? What are the consequences of these high costs?
15. Who is most affected by high healthcare costs? How do they cope?
16. What are the presidential candidates’ proposed solutions to the healthcare crisis?
The Echo Foundation 157 “One by One by One……..”
The Echo Foundation 158 “One by One by One……..” VI. Footsteps in Rwanda
h HIV at Partners In Health Health In Partners at h HIV
t
Children wi Rwanda. Rwinkwavu,(PIH)/Inshuti Mu in Buzima
Echo Footsteps Ambassadors Echo Footsteps share with students at Partners Ambassadors play volleyball In Health (PIH), Rwinkwavu, with students at Nkondo Rwanda. School, Rwinkwavu, Rwanda. Volleyballs and nets were purchased with money raised by the Footsteps Ambassadors.
Echo Footsteps Ambassadors and students from Nkondo School work together to paint blackboards. Materials— blackboard paint, rollers, and paint trays were purchased using money raised by the Ambassadors. Photos by Echo Footsteps Ambassadors.
“We are preaching hope, standing on the bones of the past.” –Bishop John Rucyahana
The Echo Foundation “One by One by One……..” Footsteps in Rwanda
This chapter was created to bring to life our experiences as Footsteps Ambassadors in Rwanda. Here, we share with you our photographs and stories that exemplify our emotions, thoughts, and activities. Through these personal accounts we hope to convey to you the very same moments of discovery, compassion and dedication that have captured our hearts and minds forever.
As part of The Echo Foundation’s 2008 Footsteps Global Initiative, twelve Charlotte-area high school students were chosen to become Footsteps Ambassadors and participate in the ECHO ABROAD: Footsteps in Rwanda initiative. These students traveled to Rwanda to study the effects of the 1994 genocide as well as the work of Partners In Health and its community model of healthcare. The Footsteps Global Initiative began in 2007 as students traveled throughout Europe in the footsteps of Holocaust survivor and Nobel Laureate for Peace Elie Wiesel. The lessons learned about the cost of indifference and the need for justice translated into this year’s study of and travel to Rwanda; a country ravaged by genocide fourteen years ago but a remarkable symbol of peace and reconciliation today. While in Kigali, we met with the United States Ambassador to Rwanda, worked with Partners In Health at its main hospital in Rwinkwavu, helped out at Nkondo primary school refurbishing classrooms and spending time with children, learned about the genocide at the Genocide Museum in Kigali, visited a coffee cooperative to learn about the economic growth of Rwanda, and spoke with Bishop John Rucyahana and representatives of his Sonrise School, all in an effort to understand how Dr. Paul Farmer and Partners In Health have been able to raise the standard of health care in one of the poorest areas of the world. We came to Rwanda expecting, unconditionally, to give; yet, as the Rwandans unveiled their love and kindness for us, we left with a profound sense of receipt—more than we could have ever desired or imagined. We received the love, joy, and happiness of a group of people who genuinely cares about their country and who wants to be a part of its rebuilding after the terrible events of 1994. People were bitter after the genocide, but they had no choice but to move on. They did not have the luxury of time to mourn, as everyone was suffering. As the U.S. Ambassador to Rwanda told us, “The whole society was turned upside-down [after the genocide]. The Rwandans have been able to survive, to pull themselves up, and to rebuild. This is truly remarkable.” The Rwandan people have given each other hope that regardless of who they are or what is in their past, they have a future in the new Rwanda. This feeling of optimism exists despite the problems of extreme poverty that are ever present in the country. While so much has been achieved, the country started from such a low base that there is still a long way to go. The genocide left emotional scars that are not easily healed. Rwanda’s greatest needs are in education, health, and medical treatment, especially for the rural population, which makes up 85% of the country. The level of poverty is so severe that many parents cannot pay their children’s school fees or provide enough food for their families. The poor in Rwanda literally cannot pull themselves up by their own bootstraps, because they have no shoes.
Murakoze chane,
Cate Auerbach Student Intern in Rwanda
The Echo Foundation 160 “One by One by One……..”
Welcoming Susan Mackey
The most startling difference between the U.S and Rwanda wasn’t the mud houses that lined the dirt roads. It wasn’t the avocado and rice we ate every day, nor was it the baboons that greeted us every morning at breakfast in the Akagera Lodge. The aspect of Rwanda that made me feel so far away from home was the Rwandans startling, in your face kindness. When we flew into Kigali, it was dark outside as we stepped off the one and only airplane at the airport. We were dazed after the eight hour ride from Brussels. After coming off the tarmac and walking through the airport terminal, we lined up to have our passports checked. The man in the booth smiled kindly at me and asked if this was my first time to Africa. Yes, I told him excitedly. I expected that to be the end of my relationship with the man in the booth. But he went on to ask about my trip and to wish me a good stay. Then, looking at my passport, he asked me what the meaning of “Lee” was. “It’s my middle name,” I told him. “It doesn’t mean anything.” “Is it Chinese?” he asked. “No,” I told him, laughing a little. “It’s Southern.” I had never been faced with such kindness by a complete stranger.
Luckily for us, his hospitality was not unique. For the rest of our stay in Africa, I met more kind strangers than I could ever expect to meet in Charlotte. During home visits, a woman with HIV/AIDS welcomed us into her home and, before we could even speak to her, she said a prayer asking God to watch over us while we were in Rwanda. Perhaps the most astonishing example of this friendliness occurred when we were walking with Grace, our interpreter. As we’re talking, Grace quietly and casually slipped her hand into mine, and for a few moments we walked together holding hands. Never before had I met someone so brave as to hold the hand of someone she just met. It’s a hard concept for me to wrap my head around; in the U.S. we are more afraid, or apprehensive, of intimacy than the Rwandans. After all, in Africa we saw little boys walking with their arms wrapped around each other, and grown women holding hands. How often do we get to see that kind of unabashed love in Charlotte? Back in America, my heart aches for the closeness I felt with all the people that I met, and I can do nothing but try to spread that joy that was in Africa with people I know and love here.
The Echo Foundation 161 “One by One by One……..” Partners In Health Andy Thomason
The Partners In Health (Inshuti Mu Buzima) center in Rwinkwavu is located directly off the main dirt road of the village. There is only a long driveway separating this modern facility from the poverty-stricken Rwandan countryside. In many ways the two places are inseparable, indistinguishable from each other. From an outsider’s perspective, the doctor organizing medication looks just like the man pushing a bushel of bananas on his bicycle. The women cleaning sheets for PIH are the same women you see on the side of the road balancing pots on their heads as they walk. Groups of men congregate directly outside the PIH buildings, talking. It is almost impossible to know where Rwinkwavu ends and PIH begins, aside from the trademark shade of blue that covers every PIH rooftop. These examples are representative of PIH’s model of care: “Partnering with poor communities to combat poverty and disease.”
PIH addresses everyday needs that are often neglected by health organizations. The Kiva microfinancing project of PIH posts on the Internet pictures of locals who need business loans. An outline of the business plan helps potential donors match their goals to those of businesses in need. This project allowed one HIV positive patient, whom we spoke with, to start a business; now he can provide for himself and his family from his profit. PIH also provides food, housing, jobs, clothes, money, and pays school fees for those who need them the most.
This holistic approach is what separates Partners In Health facilities from hospitals in the ‘first world.’ It may, in fact, be unjust to label the PIH facilities hospitals. It would be more accurate to call them community centers. Dr. Michael Rich, PIH Rwanda Country Director told us of how, during the 2004 World Cup, the PIH staff hooked up a projector to the satellite feed for mass viewing. Hundreds of villagers from all over came to watch. It is in this spirit that PIH conducts business, healing the community broadly, rather than only case by case.
PIH certainly holds the interests of the community as its greatest priority. It has built countless houses for patients in the area. It also supports local businesses, such as Vestine’s store, which sells handcrafted merchandise less than a mile away from the PIH facility in Rwinkwavu. Of course, there are critics who disagree with this community-based approach, stating that more people could be treated if PIH would concentrate resources solely on medical treatment rather than on the community as a whole. However, this would compromise the PIH philosophy that all people have the same right to quality healthcare. Every PIH patient receives the same high-quality treatment on the beautiful PIH grounds; PIH is concerned with healing for all of its patients.
In Rwanda it costs roughly $1,000 to keep someone alive for a year. In the United States it costs roughly $30,000. The United States healthcare system is, as Dr. Gene Bukhman, head of cardiology at PIH, told me, “a disaster.” It almost makes someone wish for a PIH center closer to home.
The Echo Foundation 162 “One by One by One……..” Dr. Lisa Hirschhorn and HIV/AIDS Michael Nole
The Partners In Health clinic in Rwinkwavu, Rwanda cares for many easily treatable diseases that are pandemic throughout the country, such as malaria, tuberculosis, and HIV/AIDS. It is the collaboration of many international doctors who specialize in such diseases that makes accessible healthcare possible. Dr. Lisa Hirschhorn, Associate Director of International Programs at Harvard Medical School's Division of AIDS, is one of many international doctors offering their expertise to the clinic.
As a medical student in the early 1980's, when the first HIV cases were being described, Dr. Hirschhorn entered into a very controversial field of study. She has made great contributions to the development of efficient, reliable systems for delivering care to HIV/AIDS patients who would otherwise not receive proper treatment. A long time friend of Paul Farmer's since their time at Harvard Medical School, Dr. Hirschhorn gravitated toward the PIH project and has been conducting extensive research with the Rwinkwavu clinic. "PIH has raised the bar of expected healthcare," she says. "They have taken a much more holistic approach to healthcare within the context of human rights." With this holistic approach in mind, Dr. Hirschhorn works with PIH to ensure health system responsiveness making sure that, in addition to a high quality of healthcare, patients at the clinic feel respected.
Dr. Hirschhorn also works with PIH on developing adequate monitoring and evaluation systems. By creating ways to effectively compile adequate documentation of the patients seen by the clinic, PIH can examine how many people in the community have been served; and out of those people, how many came back. With this data, the PIH clinic can get a better understanding of what methods have been working and what should be changed to improve the quality of healthcare provided to the patients.
What does it take to get the pill to the person? According to Dr. Hirschhorn, this is the bottom line, and in order to properly do so PIH is strengthening the community as they improve health. But how do they know whether their efforts are truly working? Dr. Hirschhorn argues that the answer is simple: they know they are doing a good job "because many of the burial services in the area are going out of business." The progress that PIH is making in Rwinkwavu is also evident in the healthy faces of its patients, many of whom are even employed by the clinic as gardeners or as community health workers. Many of PIH's patients are happy to share their stories and have no problem revealing an HIV+ status. As Dr. Hirschhorn puts it, "people aren't dying," so in the eyes of HIV+ people and the entire community, HIV is no longer "seen as this frightening, fatal disease, but rather as a lifetime illness."
Dr. Hirschhorn likes to travel two weeks every two months, which is quite impressive when both of her jobs are taken into account; not only does she work for Harvard Medical School's Division of AIDS, but she also manages to raise a family. When her kids go to college, however, Dr. Hirschhorn plans to spend up to twenty-five percent of her time offering her expertise to health clinics throughout Africa. Her current goals within Harvard Medical School include a push to use the Harvard endowment not only to send students to Africa, but to also strengthen the infrastructure of the countries they are helping.
Dr. Lisa Hirschhorn and her PIH colleagues, are among many who have jumped at the opportunity to volunteer their expertise to the clinic not only because they see a great need in the impoverished people of the area, but also because of the overwhelming feeling of hope and pride that the patients exude. From the second we arrived at the PIH center in Rwinkwavu, the exuberance of the patients, families, and workers we met throughout the clinic was impossible to overlook, and it is obvious in the beaming faces of children and adults alike that the hard work and dedication put in by the various volunteer doctors has really paid off.
The Echo Foundation 163 “One by One by One……..” Home Visits Suzanne Fleishman
Partners In Health has been able to completely revolutionize the system of healthcare in Rwinkwavu. This is not just noted by the statistics, but by the people receiving treatment, who are more than overjoyed to tell how much PIH has helped them. We were able to go on several home visits and talk with PIH patients and community health workers during our time at the clinic. Many community health workers we met became accompagnateurs when a neighbor asked them for help, while others began as patients and then wanted to help others. Accompagnateurs take care of about six patients and visit their homes every day to ensure that the patients take their medications and aren’t having any complications. Each home is about a 10-15 minute walk away. Community health workers are an integral part of the PIH model and pivotal to PIH’s success because they make sure that patients take their medicine and are getting the help they need.
Furthering the success of their work, Partners In Health has even changed the way that the community views HIV/AIDS. Now that nearly everyone in the Rwinkwavu area is tested, many patients are not ashamed to reveal their status. One woman expressed that before PIH started, she would lay in her hut sick all day and no one would take care of her because of the stigmas attached to HIV/AIDS. With the help of PIH and her accompagnateur, she moved, began taking medication, and is now respected in the community and back to normal life. One man explained how his HIV/AIDS support group helps him remain educated about his status and how to best manage the disease. Before PIH came to the area, few knew of their status or even what HIV/AIDS really was.
One home that we visited was occupied by an HIV positive woman, her husband, and four children. The husband had been arrested in 1994, as he was suspected of being one of the perpetrators of the genocide. While her husband was in jail, the wife had an affair with her neighbor. It was from this man that she contracted HIV/AIDS and gave birth to three of her four children. In 2005, when PIH came to Rwinkwavu, she was tested and began treatment. At that time, her family was living in a tent on their small property; because of her sickness and small children, she was unable to cultivate much food for her family. PIH provided the family with a food package for ten months and built them a modest house. When the Gacaca courts determined in 2007 that the woman’s husband was actually innocent, he came home to the shock of finding three children and a wife with AIDS. Although it was very difficult for him to accept the situation at first, with the help of counseling from PIH, the couple now has a stable marriage. The biggest challenge they face is being able to take care of their children, but now with the husband home they have a small crop of vegetables, banana trees, and even a few pigs.
With every home visit a trend occurred. Each home had an adult with HIV or AIDS who was being treated with antiretrovirals (ARVs) from PIH. The strength regained with the medicine along with either jobs, homes, or food provided by PIH allows for these families to lead a normal life. All are grateful for Partners In Health, which has completely changed their quality of life and helped them to be healthy and productive individuals.
The Echo Foundation 164 “One by One by One……..” Nkondo School Dylan McKinney
In preparation for our visit to Nkondo Primary School, we Footsteps Ambassadors raised nearly $20,000 to be used improving the school facility and sports fields and to providing school supplies and cabinets. We wanted to assist in making the improvements; therefore, the school was our first destination in Rwanda. There we were greeted warmly by the principal and students who had returned to the school, despite their summer break. Our cameras provided an immediate bridge to the Rwandan students and, the little Kinyarwanda we knew at the time was immediately put to use. After an initial introduction, we were invited to take our seats in a make-shift auditorium providing the only shade available. The principal of Nkondo, with the help of Grace, our translator, began to explain the schedule for the two and a half days we had with the School. The itinerary included refurbishing soccer fields, sanding and refinishing chalkboards, and varnishing cabinets in the morning; lunch, and games and cultural activities in the afternoon.
Instead of a second suitcase, each Footsteps Ambassadors was given a 50 pound box of school supplies to carry with us. The brand new cabinets we had arranged to have built, were waiting for our arrival. Each Footsteps Ambassador was assigned a group of approximately ten Nkondo students. The painting supplies were unpacked and distributed, and so the work began. In the smaller setting of the individual classrooms, we were able to exchange with the Nkondo students our respective cultures.
With paint brushes and rollers in hand, a new coat of black paint was applied to clean chalkboards, and glaze to the new cabinets. Our work day came to a close as we prepared to have lunch. A row of tables were lined up in the center of the first classroom. Placed on top were tubs of rice, beans, pineapple, avocado, fries, and tomato sauce. Everyone entered single file in “conveyor belt” style; we could help ourselves to as much or as little food as we liked. Afterward, plates and utensils were recycled in a wash bucket and dried for anyone in need.
For the remainder of each day games and activities took place in the field behind the school; soccer, volleyball, and frisbee were among the favorites, although we also played smaller games of hacky sac, duck duck goose, and ball toss. Later, Rwandan students presented native dances in the small arena by the shaded area where we took our seats once more. Here, traditional dances were performed by the students as they moved to the beat of their drummer in coordinating costumes. At the close of each song, Echo students were invited to join the dancers. We were not nearly as graceful as the Nkondo students! In performing skits, the Nkondo students demonstrated the English they had been practicing and preparing for us. Then it was our turn to perform. We sang songs including “Lean on Me”, “I Believe I Can Fly”, and in closing, our national anthem. We used our increasing vocabulary of Kinyarwanda to perform a small skit. We also demonstrated games like the “Hokey Pokey”, “The Electric Slide”, and “The Limbo”, which we invited them to join.
Nkondo and Echo students had the opportunity to share work, music, dance, meals and games in a cultural exchange which technically lasted only days, yet created memories that will never be forgotten.
The Echo Foundation 165 “One by One by One……..” The Bishop of Rwanda Alex Gunn
Ten years ago Bishop John Rucyahana had a vision for the future of Rwanda: “Something must be done for these children [the orphans], or we will lose a whole generation.” The Sonrise School, started by Bishop John in 2001, has grown into the “something” that he spoke of. From that point, the Sonrise School has become successful, annually ranking among the top ten schools in nation-wide standardized tests. While we toured the school it became obvious that it was among the best: the facilities seemed well designed and well maintained; the students spoke English very well, and the teachers seemed well-trained in their fields.
After the success with the Sonrise Primary School, the Bishop began to raise money for a Secondary School, which opened in 2005. Now the Bishop is again looking to the future: a Sonrise University. When we met with Bishop John, he made it a point to tell us that his goal is to train students to become the future leaders of Rwanda. He is giving Rwanda hope.
This optimistic look to the future is also found in Bishop John’s book The Bishop of Rwanda: Finding Forgiveness Amidst a Pile of Bones. In it he writes, “There is no barrier that cannot be overcome and no division that cannot be healed…it is through repentance and forgiveness that people can relate again. They can live life together again. No one believed that this could happen in Rwanda. Everyone said, ‘It’s impossible. These people cannot be together again.’ It is hard, but it is not impossible – we are doing it!” The statement is indeed true: “We [Rwandans] are doing it!” As our group traveled through Rwanda, one of the things that became increasingly apparent to us was that everyone was unified.
In March, Bishop John delivered a similar message when he came to Charlotte. He spoke in the Student Dialogue at Charlotte Latin and again at Queens College. After the Student Dialogue, he held a press conference with students and a few members of the press that gave students a more intimate setting to ask him questions. One of the defining moments of Bishop John’s visit was at the student dialogue when he declared, “If asked whether I am a Hutu or a Tutsi, I reply, ‘I am Rwandan.’”
Located in Ruhengeri, the Bishop preaches in the Shyira Diocese Episcopal Cathedral, which is both magnificent and majestic. On Sunday mornings Bishop John, dressed in red and white, preaches sermons that are infused with feelings of hope and reconciliation. These same messages are delivered every day at Partners In Health through community work and human compassion. Hope and reconciliation are the principles on which the future of Rwanda will be built. Bishop John and members of Partners In Health are the bricklayers creating this firm foundation for all of Rwanda.
God is truly in Rwanda He is in the landscape He is in the people He is in the wildlife He is Hope
The Echo Foundation 166 “One by One by One……..” Genocide Memorial Gabby Reed
Fourteen years ago, a two-year-old girl named Aurore spent her time playing hide and seek with her brother. She also loved cow’s milk, and she was talkative. But she met the same fate that as many as one million other Rwandans did. Aurore died during the Rwandan genocide, burned alive in Gikondo Chapel. I have read of the genocide many times, in textbooks and online. Yet during the Footsteps Ambassadors’ trip to Rwanda, I stood in the children’s memorial at the Kigali Memorial Centre, and I was overwhelmed. The exhibit, which tells the stories of 14 children, skips over the sort of generalized statements often used to describe tragedy, and instead takes a poignant look at the true meaning of each lost life. Besides the children’s memorial, the Kigali Memorial Centre includes a beautiful and expansive garden with several mass graves, as well as an exhibit dedicated to the Rwandan genocide, and another to other twentieth- century genocides around the world. Outside the memorial’s main building, in the center of a pool of water, stands a tall, flaming torch. As we later learned, the fire burns each year for roughly 100 days beginning on April 6th, the same days as the genocide occurred in 1994. The surrounding garden is divided into three levels: Division, Unity, and Reconciliation. Each symbolizes a period in Rwanda’s history. We also visited the Nyarubuye Genocide Memorial, located in the country’s eastern province. There, more than 20,000 people were killed over two days in 1994. The area remains largely as it was, with a church (no longer in use), a building that has been turned into a memorial exhibit, and a memorial garden. Our group of 12 students was led through this exhibit, almost terrifying in its authenticity. We saw piles of clothing taken from dead victims and the shoes from young children’s feet, and we were told of how hollowed-out logs were once used for decapitation. We entered a room with row after row of skulls and other bones, and we looked on as our guide described how babies were thrown into pits of fire in front of their helpless mothers.
Outside, staring at the large and beautifully simplistic church where so many had died, I was reminded of the words I had heard from a genocide survivor, only days earlier. “People hid in the church—because, we thought, no one can go in a church and kill.” I wondered how many had stood on these same grounds and believed in their own safety, only to realize, moments before dying, the horrible fallacy of these words. At the Kigali Memorial Centre, an inscription reads: “If you knew me and you really knew yourself, you would not have killed me.” The quote, attributed to genocide survivor Felicien Ntagengwa, speaks to the lack of human awareness that was a pre-condition to so much senseless killing.
Through our trips to the memorials in both Nyarubuye and Kigali, we as a group were taught the painful lesson of human nature and all that it entails, from enduring hope to murderous cruelty. And in this lesson, we also realized our striking similarities to the victims of the genocide. In 1994, like Aurore, I was two years old. It was merely chance that saved me from her fate.
The Echo Foundation 167 “One by One by One……..” Egide Rugwizangoga Jocelyn Ruark
Midway through our travels in Rwanda, we discovered that Egide Rugwizangoga, our animated driver, had a troubled past of his own resulting from the genocide. As he told us his story when we visited the home of his childhood, he remembered aloud that, even when the shooting had stopped, his aunt and he remained hidden beneath bloody bodies. When they could not breathe anymore from the stench, he slowly crawled out first to make sure it was safe for his aunt, and the baby strapped to her back, to emerge. As they stood there, he looked around with horror and shock as he realized that about 300 people lay dead on the ground around him. Almost the whole group was fleeing the local church in his home village of Kamonyi for a large cathedral called Kabgayi Cathedral, about a four-day walk away. They thought that they would find safety in numbers, but were ambushed at a bridge by a large group of men.
Suddenly, he heard his aunt wailing. He quickly went over to her, but then backed away, when he realized she was crying because somehow in all the commotion, her baby’s had been shot off while he was on her back. The baby had saved his mother’s life by taking the bullet. One inch over and the bullet would have completely missed the baby and killed Egide’s aunt.
Not only did Egide lose one of his best friends, his baby cousin, his older brother, another aunt, and have his father’s remains disrespected, but many of his sisters were also raped. When Egide finally reached Kabgayi Cathedral there were 14,000 other Tutsis and Hutu sympathizers hiding there. Egide knew of another cathedral by Kigali that had 50,000 Tutsi and Hutus hiding in it that was literally bulldozed by the perpetrators, killing all. Egide feared that would happen at Kabgayi Cathedral too, but luckily it did not. Instead, about 100-200 people were pulled out everyday to be killed. Egide told me how frightening it was to have to stand in line everyday and realize that today he could be killed, or tomorrow, or the next day. Although Egide’s family was never taken, when the Rwandan Patriotic Front (RPF) liberated the cathedral in July, only 2,000 of the 14,000 people who originally took refuge in the church remained. I cannot imagine having to deal with so much death, destruction, and fear at the young age of fifteen.
Directly following the genocide, Egide’s family lived in a refugee camp. When they finally returned home, they found their house destroyed. Egide finished secondary school and began university but realized that he could not support his younger siblings and so dropped out and began work, including picking roses. Once he was a little older, he began his own business as a driver and guide for tourists in Rwanda. Egide is now so well known that he drives celebrities like Bono, Ben Affleck, and Dr. Paul Farmer. This year, Egide will come to Charlotte to share his story. He is extremely inspiring because he is funny, humble, trustworthy, forgiving, and more. Once you hear him tell his story, you’ll never forget it.
The Echo Foundation 168 “One by One by One……..” Reconciliation Rachel Myrick
I could tell by their faces when I told them where I was going. Some would appear stunned, others more subtly perplexed. All seemed to associate Rwanda with the 1994 genocide, an uncivilized place of violence and corruption deemed unfit for foreigners. Rwanda was a dangerous place.
I arrived in the country filled with apprehension. My money belt fastened securely around my waist, I was prepared for lingering traces of hostility. Perhaps the tension wouldn’t be quite so conspicuous, but I was sure I would be faced with mistrust, sensitivity, or outbreaks of violence. I waited. I saw rows of banana trees and entire families of baboons sitting on the dirt road. I saw children lugging empty gasoline containers full of water from the local pump. But I saw no evidence of division. There were no discernible physical differences between Hutus and Tutsis. The children of the next generation seemed oblivious to the atrocities of times past.
Yet, throughout my journey, I couldn’t understand how the dream of a reconstructed nation became reality. Rwanda was undoubtedly spurred toward its path of reconciliation through strong leadership. President Paul Kagame announced, “We cannot turn the clock back nor can we undo the harm caused, but we have the power to determine the future and to ensure that what happened never happens again.” However, an explanation of leadership or a legal system did not seem sufficient. And after two weeks of searching, I found the answer.
I saw it in the faces of the children at Nkondo Primary School, the warmth of the volunteers at Partners In Health, the profound stories of the average citizen. It was the undeniable spirit of hope that resonated in action and in expression, the desire to renew beyond that which is tangible.
In any circumstance, of course, it’s a fallacy to believe that the scars of such atrocities will ever completely fade. The long term effects of genocide continue to permeate society. The systematic rape of women and children has led to outbreaks of HIV/AIDS. Persistent economic difficulties following the genocide stem from a lack of infrastructure. Most evident are the thousands of orphaned Rwandans who remain behind. We met one group of homeless teenagers who lost their families during the genocide. They now live in a vacant lot in Kigali; their only shelter is a sheet of tin propped up against a wire fence.
And, finally, there remain the stories. When one of the local children committed a wrongdoing at Nkondo School, our driver, Egide, reminded him of the Gacaca courts. In the courts, he explained, perpetrators were forgiven if they admitted their crimes. The boy apologized publicly, showing that the concept of reconciliation still remains a meaningful part of Rwandan society today. Egide, a Tutsi who lost four siblings to the genocide, truly believes in the concept of forgiveness he speaks so openly about. He now shares his house free of charge with a wounded veteran. That man is Hutu.
Now, the first images that come to mind when I think of the country will no longer be related to genocide. They will be fleeting snapshots of clay huts surrounded by banana trees, sleeping infants fastened to the back of the mothers, children sprinting after our truck and waving with both hands.
The Rwanda that I saw, the one I was privileged to enter into and carry away a piece of, stands unified. It is unified in the belief that an idea can no longer tear a nation apart. Today, due to the wisdom and faith of its people, Rwanda serves as a paragon of reconciliation, a thread of hope woven into our tumultuous world.
The Echo Foundation 169 “One by One by One……..” Maraba Coffee Cooperative Hannah Heidenreich
Kawa: the word coffee in Rwanda’s national language, Kinyarwanda. This yummy bean that creates the caffeinated drink so desired by many around the world has become a means of prosperity for women in Rwanda. During the 1994 genocide, many men were killed, leaving thousands of women and children desperately alone to provide for themselves. A great number of women throughout Rwanda became widows and had to take over their family coffee farms. Knowing that they could not waste time grieving their losses and hoping for a solution, the women of Rwanda realized that they would have to rebuild what was lost on their own. Many women came together to help one another reestablish the economy by combining their efforts. The Rwandan government and international organizations, such as USAID, help the cooperatives produce more and higher quality coffee which we visited. At the Maraba coffee cooperative in Butare, members learn new methods of harvesting as well as business practices, resulting in greater success and productivity. Thanks to the co-op’s great efforts after the genocide to continue and even increase coffee production, business has improved tremendously throughout Rwanda.
A woman by the name of Cecile is one of the locals who co-founded the Maraba Coffee Co-op. She has been a member of the cooperative since 1989, and became permanent staff in 2000. Cecile was born in the Butare area and is a survivor of the genocide. Her home was burned and she lost both her husband and her brother. She took over her brother’s coffee farm after the genocide and now has a home near the co-op. When she started her business, her farm had only 450 coffee trees, and it now has 750 trees because business is going so well. Cecile has six children; she can now provide enough food and clothing for her family, and pay school fees for all of her children to attend school due to income from coffee sales.
In addition to economic change, social change has occurred in Rwanda as a result of women working in the coffee business. Before, women were thought incapable of doing business, and now women all over the country are taking charge. Ninety percent of the coffee at the Maraba cooperative is produced by women. Women are even outperforming men in towns such as Butare, where men work hard in the mornings but rest in the afternoons, while women work all day. Women also are more likely to spend their money on food or their children’s school fees instead of on banana beer at local pubs. The substantial number of women in the Rwandan parliament illustrates the new view of females in society. The role of women in Rwandan society continues to grow as women like Cecile take the initiative to rebuild and improve their reconciling nation.
The Echo Foundation 170 “One by One by One……..” Lasting Impressions Clare Rizer
His name is Peter. He is 16 years old, just like me. Our similarities are striking. We play soccer and basketball; enjoy the hip-hop artists Akon and Sean Paul; and love dancing, reading, and just being silly. Our differences, though, are more telling of the different worlds from which we come from. Peter lives in Rwinkwavu, Rwanda. He survives off $300 annually for his entire family. He has been a witness and a victim of a genocide that claimed the lives of one million people. And, he will probably never get past primary school because of his family’s income— a situation with which almost every Rwandan can identify. I met Peter at the Nkondo primary school where we Footsteps Ambassadors helped refurbish classrooms and played sports with the children. All of the children were amazing athletes and I was "schooled" plenty of times during our soccer game, despite my premier level training back in America. The genuine joy on the faces of those students brought immediate happiness to my life and I couldn't help but smile every time I saw their glowing faces.
After leaving the school, I was skeptical as to where I would find as much love as I felt with the Nkondo students. The answer: a drum circle composed of homeless Rwandan boys, many of whom were orphans and victims of the genocide. One night in Kigali, our group was the guest of these boys who had been working for many months on a tune to play for our arrival. The energy in that room was electric! As I looked around at the other Footsteps Ambassadors I saw feet tapping, hips swinging, and a compilation of bodies swaying back and forth to the music of the night. We started dancing with the boys and eventually formed a conga line where the Americans found it a struggle to keep up with the smooth rhythm of the Rwandan boys. After working up an appetite, we traveled to a local restaurant to feast with our new friends—and what a feast it was! We ate side by side, alternating American and Rwandan in every other seat. However, I felt like I was surrounded by good friends throughout the whole meal as we were taught complex Kinyarwanda from the boys. Needless to say, our attempts to use Kinyarwanda were awkward and incorrect, but laughing with the boys at our mispronunciations was, surprisingly, fulfilling and made me feel that we were all just normal teenagers sharing in fellowship.
Lastly, and perhaps most difficult, was our play date with the HIV-positive children at the Partners In Health clinic. When we walked into the room it fell silent, and the shrieks and cries were no longer present. The children were mesmerized by us "muzungu" (white person) and they let us know it. We began to color with the kids, using school supplies that we had raised money for. The kids drew us pictures, mostly of houses, and gave them to us as a token of their affection. The thought and time that they put into each picture was stellar, and the care with which they drew straight lines meant so much, as they wanted to give us something perfect. When it was time to go, we sang "Ain't No Mountain High Enough," a song almost too appropriate for their present situation. Tears welled up in my eyes as I contemplated their potential futures; I longed to give them the hope that I had felt since I landed in Rwanda.
The relationships that I made in Rwanda with the local children were experiences that I will forever take with me. I hope to share the love that I felt there with everyone I meet.
The Echo Foundation 171 “One by One by One……..” Kinyarwanda
Kinyarwanda is the official language of Rwanda and is spoken throughout the country. These are some of the words that we found most useful during our trip.
English Kinyarwanda Hello Muraho Good morning Mwaramutze How are you? Amakuru I’m very well Nimeza chane What’s your name? Nitwande My name is Nitwa What’s up? Vite It’s good Nibjiza Thank you very much Murakoze chane Goodbye Murabeho Whites Amazungu Water Amaze Water bottle Agachupa Yes Yego No Oya
Echo Footsteps Ambassadors and colleagues at the United States Embassy in Kigali, Rwanda. Back row from left to right: Stephanie G. Ansaldo, Andy Thomason, Alex Gunn, Susan Mackey, Clare Rizer, Hannah Heidenreich, Cate Auerbach, and Michael Nole. Front row from left to right: Jocelyn Ruark, Dylan McKinney, Rachel Myrick, Gabby Reed, Suzanne Fleishman, Julie McConnell, and Hans Diessel.
The Echo Foundation 172 “One by One by One……..” Reflections
“Having the opportunity to study the work of Partners In Health, partner with Nkondo Primary School, and meet living examples of a reconciled society showed me the capacity of humanity to come together and make positive change in the lives of others, no matter the circumstance. I hope to share the messages from our trip with those I encounter this year and throughout my life, so that everyone can know the beauty of Rwanda.” —Cate Auerbach
“The optimism and strength of the people who lived there showed me that, no matter the conditions, you can be proud and happy with what you have. True happiness…lies within self- worth and solid relationships. Although all of the Rwandans we met seemed so optimistic, I also learned from PIH that there is still a lot to be done. Their standard of living is inhumane and they deserve all of the same opportunities that we receive here in America. The words of the workers from PIH have instilled in me a great desire to devote as much as I can to those less fortunate in the future. I know I will take everything I learned this summer, add to it, and use it to educate others so that I can make a difference.” —Suzanne Fleishman
“Some may choose to be ignorant to the problems of the world, but on this trip I have seen these problems and now I am charged with responsibility to combat them. This is only fair because this trip has also empowered me with the knowledge, experience, and human compassion to do so. The next step is taking the tools handed to me and using them to serve the community through action.” —Alex Gunn
“From my Footsteps experience I have learned to let go, try new things, speak up, and leap at every opportunity that is worth taking. As I go through my daily activities for the rest of my life I will always remember the faces I saw, the hands I held, and the people I met. When I remember Rwanda, life will seem much bigger than many of my activities, goals, and even problems, therefore, I will have to remember to live life differently. I now have no excuse to be ignorant.” —Hannah Heidenreich
“The most important thing that I learned from Rwanda was how courageous humanity can be, even after a crisis like the genocide. Egide, especially, showed me how strong the human heart can be. I hope that for the rest of my life I show the same strength and dignity that the Rwandans have.” —Susan Mackey
“I feel as though I have a deep understanding of Rwandan culture and history; a personal connection that continued to develop as my knowledge of their past did … I realized how far Rwanda had come, and how determined they were to improve their country, to ensure brighter futures for their young ones. What I had witnessed was that the forgiveness and gratefulness of the Rwandan people was a part of a healing process; a process that every Rwandan understood was necessary in order to improve the future. It is this memory, and many more that I will possess for a lifetime. But the knowledge and understanding of Rwandan history I have gained, I am responsible for sharing—my service to the Rwandan community at large.” —Dylan McKinney
The Echo Foundation 173 “One by One by One……..” “I returned home burdened by the weight of renewed consciousness. I remember the countless children who looked at me, a foreigner, not with bewildered eyes, but with an inexplicable sense of hope and resolve. If I truly believe that their futures are just as important as my own, should I not feel an obligation to generate awareness of their plight? How can we collectively begin to ensure that these children and so many like them have access to clean drinking water? To health care? To education? Recalling the memories I feel fortunate to have taken away, I hold one thing true—these are the questions I hope I will spend the rest of my life pursuing.” —Rachel Myrick
“I learned how easy it is to find similarities between people from opposite sides of the world, despite the obvious cultural, geographic, and socio-economic differences.” —Michael Nole
“I have always believed that I could change the world, but there is a great difference between an ignorant belief and an enlightened one, between hoping to point a wand and realizing that there is a price to pay for change. Traveling to Rwanda made me brutally aware of just what it means to say, “I will help you,” to vow to save the world, to make a pledge to a people who have lived through so many broken promises. I have never felt more strongly the reality of what it means to commit to changing the world, but in spite of that, and perhaps because of it, I am more empowered than ever to do so.” —Gabby Reed
“From this day on I will carry with me the love I felt from all of my fellow ambassadors and the memories that we share of helping our Rwandan friends, taking 5 hour car rides along bumpy dirt roads, playing with HIV positive children and attending Bishop Rucyahana's service where we all sang and danced and felt the love truly radiate in all of our hearts. With this knowledge I've gained about the sheer power of love I know that I will be showing more love to all I meet and using it as an impetus to create positive change in my life and the lives of those I meet.” —Clare Rizer
“It is difficult to comprehend that the Rwandan genocide claimed 1 million lives in 100 days. To truly grasp the enormity of the tragedy, it is necessary to break down the numbers and think of the murder of each individual. Personal accounts of survival and devastating loss, such as the story told by our driver, Egide, help give the genocide a face. After traveling to Rwanda and learning to think about genocide in this way, I have channeled my interest in political science to the specific field of genocide studies.” —Jocelyn Ruark
“By exposing me to individuals of disparate backgrounds and diverse customs, the Footsteps program has allowed me to gain a more comprehensive perspective on the human condition that I can apply to understanding international issues as well as my everyday life. The lessons I learned from this experience will most certainly alter my life’s course, and I can say with certainty that I am a better person because of it.” —Andy Thomason
Footsteps Ambassadors from left to right: Suzanne Fleishman, Alex Gunn, Jocelyn Ruark, Clare Rizer, Michael Nole, Dylan McKinney, Andy Thomason, Hannah Heidenreich, Cate Auerbach, Gabby Reed, Rachel Myrick, and Susan Mackey. The Echo Foundation 174 “One by One by One……..” WE NEED YOU! ECHO and NKONDO School
The Echo Foundation’s 2008 Footsteps Student Ambassadors raised nearly $20,000 for Nkondo School in Rwinkwavu, Rwanda. Located in one of the most impoverished regions of Rwanda, Nkondo serves 1075 students with just 12 teachers and few supplies. Among other things, the money from this year’s fundraising bought for the school:
• 60 boxes of blackboard chalk • 45 boxes of pencils • 1075 notebooks • 1075 erasers Some of the supplies for Nkondo School purchased with • 1075 pencil sharpeners money raised by Echo Footsteps Ambassadors. • 183 boxes of crayons • Paint for school walls as well as chalkboard paint to refurbish blackboards
The Footsteps Ambassadors transported many of these supplies as check-in luggage on their trip to Rwanda.
This year, Echo is renewing its commitment to Nkondo School. We hope to raise money for the following initiatives at Nkondo, as well as others to improve its quality of education:
• Textbooks for Nkondo Primary School • School fees for needy students • A professional English teacher to provide more effective English instruction • Bathroom repairs • Water tanks to collect rainwater during the rainy season • Laptops for teachers and students to access educational materials otherwise requiring costly textbooks • Agricultural assistance to the community
Any amount would be of immense help to our cause: This year, most of these supplies cost less than $5 per unit.
To donate to Nkondo School, please visit The Echo Foundation’s Website— www.echofoundation.org.
Æ On the left hand scroll bar, click “Donate.” You will be linked to Echo’s secure PayPal site. Æ In the “Purpose” field, type “Nkondo School.”
The Echo Foundation 175 “One by One by One……..”
The Echo Foundation 176 “One by One by One……..” VII. In the Classroom
Based on enrolment data, about 72 million children of primary school age in the developing world were not in school in 2005. 57% of them were girls. (MDG Report, 2007)
From the Am. Red Cross.
n elementary school student in in student school n elementary Red the by provided oymilk, A s Cross. Vietnam enjoys a package of of package a enjoys Vietnam
First Lady Laura Bush with Students from Nkondo School in children at Rafael Pombo Rwinkwavu, Rwanda. Photo by Foundation in Bogotá, Echo Footsteps Ambassadors. Colombia. From the White House/Shealah Craighead.
French President Nicolas Sarkozy visits students in southwestern France. From the AFP/EJP.
Worldwide, only 60% of children of Nearly a billion people entered the 21st secondary school age attend secondary century unable to read a book or sign their school. (UNICEF, 2008) names. (UNICEF, 1999)
The Echo Foundation “One by One by One……..” Topics for Debate
Provided below is an example of a debate format. The debate can be organized with the formation of three teams: Team A, Team B, and the audience. We recommend no more than six people in teams A and B. The debate is broken into four segments that team A and B will, in turn, complete. The questions segment in the debate will be guided by the audience. Following the debate, members of the audience will write a one-page paper describing their position in support of or against the debate topic. Below are several topic ideas for debate. Topics for the debates are taken from subjects discussed throughout the curriculum guide. Attached to each debate topic is a list of suggested articles to read in preparation for the debate. Team A is in support of the debate topic. Team B is opposed to the debate topic. Total estimated time approximately 60 minutes.
Opening Statements (3 minutes) Brief introduction and overview of the team’s position. Case Presentations (10 minutes) Team presents position. Rebuttals (5 minutes) Each team will have a chance to reinforce their position and respond to statements made by the opposing team. Questions (20 minutes) After hearing both sides of the argument, the audience has the opportunity to ask each team questions. Closing Statements (3 minutes) Final closing remarks
Debate Topics • Drug patents should not be comprehensive; life-saving drugs should be readily acquired.
Suggested readings: (p. 107) “Drug Patent Rules Must Allow Exceptions for Public Health”; (p. 109) “WHO Promotes New Strategies to Combat Threats to Global Public Health.”
• User fees should be removed from health clinics; they restrict access to healthcare and marginalize the health of the poor.
Suggested readings: (p. 111) “User Fees: A Necessary Evil?”; (p. 114) “BURUNDI: Side Effects of Free Maternal, Child Healthcare.”
• PEPFAR’s “Abstinence” and “Be faithful” programs are extremely vital to the containment of HIV/AIDS; funding for those programs in PEPFAR 2 should not be reduced.
The Echo Foundation 178 “One by One by One……..” Suggested reading: (p. 125) “PEPFAR Reauthorization Bill Introduced as a Bold Plan to Fight AIDS; Women, Disproportionately Affected by AIDS, Stand to Benefit.”
• Liberalizing healthcare will only benefit developed countries; developing countries lack the infrastructure and resources to compete.
Suggested readings: (p. 63) “Brain Drain Hits Poor Countries Hard”; (p. 73) “Inside Zimbabwe’s Healthcare Crisis.”
Socratic Seminar Classroom Discussion About the Efficacy of International Aid
In this activity students will read (p. 68) “Why Aid Does Work”—Sachs and (p. 70) “Why Aid Doesn’t Work”—Erixon. The students will then participate in an open discussion about the efficacy of international aid. Pose the question, “Do you agree more with Sachs or Erixon; why?” Allow the students to self-moderate, taking turns to voice if aid is truly effective. Estimated activity time: 30-40 minutes.
Draw to Promote Awareness
In many countries, HIV/AIDS is extremely stigmatized. Due to this stigmatization, people with HIV/AIDS refuse to seek treatment or even get tested for fear of becoming an outcast in society. This stigmatization has created a substantial barrier in attempts to control the spread of HIV/AIDS. To alleviate fears, several countries have developed awareness programs to promote education on the disease. An effective program to promote awareness is through the use of billboards and posters. In this activity, have students design a poster or billboard promoting understanding about HIV/AIDS.
The Echo Foundation 179 “One by One by One……..” Analyze a Political Cartoon
In this activity, students can be paired into groups or work individually. Allow the students five minutes to examine each of the following cartoons on their own. Then provide the students with the following sets of questions that correspond to each cartoon. Give the students 10-20 minutes to provide their answers for each cartoon. After the students are done analyzing the cartoons on their own, collectively discuss the cartoons in class.
Cartoon #1: What is the cartoon depicting? Why is there an old man in the cartoon? Why did the clinic move to China? What is the bird in the sky? What is it doing? How does the artist depict the sky and ground? Why? What is the bird flying above? Where do you think the cartoon is taking place? What costs do you think the clinic cut?
The overall message of the cartoon is depicting liberalized healthcare. Is this the best way to improve healthcare? Should healthcare become another commodity?
Cartoon retrieved from www.seppo.net/cartoons/displayimage.php?pos=-659. Opening Answers: 1. Liberalized healthcare. 2. The old man can represent Medicare, or simply represent a vulnerable person in need of healthcare. 3. Because of China’s economy the clinic’s expenses there are a lot cheaper. 4. The bird can represent a crow, raven, vulture, or any type of scavenger bird. The crow in this cartoon is flying over the discarded pieces of the clinic looking for something useful. 5. The sky is dark and gray, representing a dark and gloomy day. 6. Mainly the United States, but it can represent any country where healthcare costs are daunting and they would seek to import healthcare.
The Echo Foundation 180 “One by One by One……..” Cartoon #2:
1. Describe Zimbabwe’s side of “new farmers.” Describe Zambia’s side of “new farmers.” How do both sides compare? 2. What is the Zambian farmer transporting? Where is he transporting it to? 3. Was Zimbabwe’s farming economy always like this? 4. How did Zambia’s economy become so developed? 5. What does the limousine represent on the Zimbabwean side?
Cartoon retrieved from hightowerlowdown.civicactions.net/sites/hightowerlowdown.civicactions.net/files/cartoon_2006_june.png Opening Answers: 1. Zimbabwe’s farming side is dilapidated. The farming mill is deteriorating along with the farming tools and equipment. The whole side looks desolate except for the limousine and scattered huts present. There is no field of crops. The only crops planted are next to the individual homes, and they are most likely used for personal use and not so much for business. Zambia’s side, on the other hand, is flourishing. There is a huge crop field, the farming equipment is advanced and working, the farming mill is fully developed, and there are farmers working and smiling. 2. He is exporting maize to Zimbabwe. 3. Zimbabwe’s farming economy was not always like this. They had the farming mill and the equipment previously, but it became derelict. They use to be the breadbasket of Africa before mass corruption. 4. Zambia’s farming economy advanced through learning Zimbabwe’s techniques when it had a thriving farming economy. Many Zimbabwean farmers have migrated to Zambia for better economic opportunity when life in Zimbabwe started to turn.
The Echo Foundation 181 “One by One by One……..” 5. For the Zimbabwean farming economy to be doing so poorly, the limousine there represents an oddity in Zimbabwe’s economy. That oddity is corruption. Money coming into the Zimbabwe’s economy has not been used to build infrastructure, go toward the development of society, or to maintain the farming industry and, instead, has been used for the personal expenses of the political elitists.
Cartoon #3: 1. What event is the cartoon drawing a parallel to? 2. Who are the people in the boat? 3. Why is the lifeboat named drug patents? Why does the man state it is a good thing that they own all the lifeboats/drug patents? 4. Who are the people in the water? Why are they in the water? 5. What is the cartoon depicting?
Cartoon retrieved from www.naturalnews.com/cartoons/aids-titanic_600.jpg Opening Answers: 1. The cartoon drew a comparison to the Titanic’s sinking. 2. The people represent drug companies. 3. The lifeboats are the mechanism that keeps the people afloat. Similarly, drug patents protect drug companies’ investments. Therefore, if they own the drug patents/lifeboats they’re secure first—and that’s why the man says it’s a good thing. 4. AIDS patients are in the water. The boat they were on is sinking. They are in the water because they do not have access to life (through drug treatment) because the drug patents/lifeboats are out of reach for them. 5. The cartoon depicts how AIDS patients do not have access to life-saving drugs because of drug patents. Drug patents allow drug companies to charge a high price for their product. Many AIDS patients can not afford the price of patented drugs and, therefore, their health deteriorates.
The Echo Foundation 182 “One by One by One……..” Political Cartoon Sketch
Have students draw a political cartoon based on the political topics covered throughout the curriculum guide. Examples of political topics are listed below. To give students an in-depth understanding of the topic, students should read the suggested articles listed next to each topic.
Women’s health (p. 42) “A Dose of Reality” Traditional healing and biomedicine (p. 55) “AIDS in Africa: A Quest for Truth” Refugees and access to healthcare (p. 60) “Refugees Denied Access to Health Care” Brain drain (p. 63) “Brain Drain Hits Poor Countries Hard” Healthcare infrastructure (p. 66) “Millennium Development Goals are ‘Just Words’ if Financing is Not Made Available” International aid (p. 68) “Why Aid Does Work” or (p. 70) “Why Aid Doesn’t Work” Zimbabwe’s government (p. 73) “Inside Zimbabwe’s Healthcare Crisis” Influence of community health workers over foreign personnel (p. 96) “Community Health Workers” Drug patents (p. 107) “Drug Patent Rules Must Allow Exceptions for Public Health” or (p. 109) “WHO Promotes New Strategies to Combat Threats to Global Public Health” Health clinics and user fees (p. 111) “User Fees: A Necessary Evil?” or (p. 114) “BURUNDI: Side Effects of Free Maternal, Child Healthcare” PEPFAR (p. 125) “PEPFAR Reauthorization Bill Introduced as a Bold Plan to Fight AIDS; Women Disproportionately Affected by AIDS, Stand to Benefit” Healthcare in the United States (p. 132) “The Health Care Crisis” or (p. 135) “Health Care Crisis: Number of US Uninsured Soars, Along With Big Pharma Profits” or (p. 139) “When Your Local Pharmacist is in Mexico” or (p. 141) “France’s Model Health Care for New Mothers”
The Echo Foundation 183 “One by One by One……..” Creative Writing
In this activity, students will write a two-page creative writing paper about a day in the life of a character(s) they chose to create from the topics given below. The setting for each character should be in a resource-poor country, except for the last topic. In their story, they will explain their character’s life by describing daily activities, certain hardships that they have to overcome, their thoughts and emotions, and their dreams. Encourage the students to coordinate several topics into their stories. The objective of this activity is to give students a keen insight into the themes covered throughout the curriculum guide.
Topics Articles to reference for further information Woman with HIV/AIDS (p. 42) “A Dose of Reality”
Teacher with HIV/AIDS (p. 49) “HIV/AIDS Delivers Heavy Blow to Third World Education”
Orphan due to HIV/AIDS (p. 53) “HIV/AIDS Reduces Children’s Education Chances” (or a student whose parents have an infectious disease)
Traditional healer (p. 55) “AIDS in Africa: A Quest of Trust”
Refugee seeking healthcare (p. 60) “Refugees Denied Access to Health Care”
Health professional (p. 63) “Brain Drain Hits Poor Countries Hard”
Person affected by conflict (p. 92) “Congo Ceasefire Brings Little Relief for Women”
Prisoner with TB (p. 100) “Siberian Jail is Champion in TB Fight”
Malnourished child (p. 38) “Malnutrition Getting Worse in India” or (p. 121) “A Life Saver Called ‘Plumpynut’”
Uninsured American (p. 138) “Free Clinic Helps People Who Need It Most” or (p. 139) “When Your Local Pharmacist Is in Mexico”
In addition to the topics, students can chose to write about a day in the life of Paul Farmer or Michael Rich.
Paul Farmer (p. 20) “Wiping Out TB and AIDS”
Michael Rich (p. 24) “Breaking Down Barriers”
The Echo Foundation 184 “One by One by One……..” Understanding the Vote Through Rapid Fire Debate
In this activity, you will investigate the rationale behind politicians’ votes.
Materials Required: Computers with Internet connection, pens/pencils, paper, approximately 30 students
Directions: 1. Divide students into five groups. Assign each group one bill to consider [A summary of the contents of each bill/Political Courage Tests can be found beginning on p. 146.] A) S. Amdt 4299 B) S. Amdt 4233 C) HR 5501: full text can be found at www.thomas.gov/cgi- bin/bdquery/z?d110:h.r.05501: D) HR 3162: full text can be found at http://thomas.loc.gov/cgi- bin/query/D?c110:1:./temp/~c110Rf3z8s:: E) The Political Courage Tests for Elizabeth Dole, Sue Myrick, and Harry Taylor, focusing specifically on their indication [under “International Aid”] of whether or not they would support U.S. aid for foreign nations with documented human rights abuses.
2. On the Internet, groups A) and B) are to conduct research on Dole, McCain, and Obama’s positions on healthcare [McCain and Obama’s healthcare position papers are included on p. 151 and p. 154 respectively]. Groups C and D are to research Myrick and Watts’s positions. And Group E is to research Dole, Myrick, and H. Taylor’s positions.
3. Divide each group into two teams: One will argue for the passage of the legislation [or in the case of group E, the validity of the policy], and the other will argue against it.
4. Ask each team to draft a position paper, no longer than one minute long [approximately one page, double spaced].
5. Ask each group to go in front of the class, setting up chairs so that each team in the group faces the other.
6. Ask each team to read its position paper; time each team to make sure that it does not go over the one-minute time limit.
7. Once each team has read its position paper, the rapid fire will begin: Each team will take 30-second turns to refute the other team’s arguments. This is to last for eight minutes without cessation.
Encourage the class to vote on which team was more persuasive.
The Echo Foundation 185 “One by One by One……..” The Economics of Starting an NGO
Many people—students and adults alike—are wary of donating to an NGO (nongovernmental organization) for fear that more of the donated money go to administrative costs than to food, water, medicines, and other direct aid resources.
In this activity, you will discover the costs associated with running a nonprofit nongovernmental agency and attempt to minimize those costs.
Directions:
1. As a class, brainstorm to determine what the NGO you create will have as its goal(s).
2. Then, brainstorm some of the goods and personnel costs necessary for running your NGO. Be sure to include funds for operations and fundraising, as well as for initiatives in the regions receiving aid.
3. For a period of one year, determine the total cost of running your organization by entering staff salaries, office space costs, utility costs, costs for supplies to be used in the aid-receiving location, transportation costs for those supplies, quality control costs, etc. into a spreadsheet. TIP: Often, companies have discounts for nonprofit organizations as well as for bulk purchases. Call around to determine the most accurate costs.
4. Determine the amount of donations necessary to sustain this organization.
5. At the most efficient NGOs, about 80 cents for every donated dollar go to aid supplies and transportation of those supplies—how much money would you have to raise for that to be possible? Can you reduce your costs so that more money goes to aid supplies and transportation?
The Echo Foundation 186 “One by One by One……..” Maslow’s Hierarchy of Needs
Adapted from Psychology, Ed. 2, by Carl R. Green and William R. Sanford; and Enhancing Self Esteem, Ed. 2, by Diane Frey and C. Jesse Carlock.
After conducting an empirical study of “successful” individuals—Eleanor Roosevelt, Albert Einstein, and Frederick Douglass among them—psychologist Abraham Maslow (1908-70) argued that in order to become accomplished, a human being has to have basic needs met. That is to say that she has to have physical needs [represented by the lowest part of the pyramid above] met before seeking fulfillment of security needs; security needs met before seeking fulfillment of social needs, etc. After ego needs have been met, a person can seek self-actualization and achievement.
In this activity, you will apply Maslow’s hierarchy of needs to the community-based approach of Partners In Health.
The Echo Foundation 187 “One by One by One……..” Directions:
1. Think of a person PIH would typically serve—likely a patient suffering from AIDS/TB/malnutrition. 2. Using a flowchart, indicate the services that PIH would provide him with as well as the results of these interventions. 3. Would someone helped by PIH be capable of self-actualization?
Shaggy has water to drink Shaggy is free from [fulfills PHYSICAL need]. disease, allowing him to . . . build a house for stability and shelter.
PIH provides Results wells for clean water. PIH provides… Self Actualization?
Norville “Shaggy” Rogers. From Warner Bros.
PIH provides… Results
The Echo Foundation 188 “One by One by One……..” Musical and Artistic “Relativism”
The development of world civilizations has always corresponded with developments in music and visual art—in the West, as well as the East. Therefore, to better understand foreign artistic media is crucial to understanding the cultures that abound in our world.
In this activity, you will conduct research on music or art to draw parallels and contrasts between Western and non-Western artistic productions.
For music students You may choose to examine the folk music traditions of any Asian or African region, nation, or tribe. Look out for similarities and differences in the musical approach of the people of your selected region when An African woman performs in native garments. compared to the Western musical tradition. Pay Public domain picture/Roger Frazer. attention to conceptions of tonality, structure, rhythm, harmony (including the presence of chordal, alberti bass, and other accompaniment figurations), counterpoint, scales (including the presence of melody), characteristics of musical pedagogy, and/or any other distinctive musical features.
For visual arts students Like music students, you may choose to examine the folk art traditions of any Asian or African region, nation, or tribe. However, you will look out for similarities and differences in themes as well as conceptions of texture, symbolism, color (including value), shapes/lines/form, perspective, characteristics of artistic pedagogy, and/or any other distinctive artistic features.
The assignment:
Write a 500-word research essay (two pages, double spaced) that details your findings and addresses whether or not the similarities in Eastern and Western artistic media justify the argument that differing cultures share fundamental similarities.
Edvard Munch, The Sir Simon Rattle conducts the Berlin Scream. Public domain Philharmonic Orchestra. From Wikimedia picture. Commons/Monika Rittershaus.
The Echo Foundation 189 “One by One by One……..” Refugee Health
This role playing activity serves as an introduction for students to explore health conditions in refugee camps.
Preparation: Photocopy and cut out identity cards. Activity assumes 30 students in a class.
Lesson Plan: Have the students read (p. 60) “Refugees Denied Access to Health Care.”
Afterward, tell the students that they will simulate certain facets of refugee life in an attempt to understand health conditions in camps. Pass out the identity cards to each student. Once the cards are distributed, have the students form groups according to the countries listed on their cards and stand at the front of the class.
Once the students are in their groups read the following brief background stories about each country.
Afghanistan: Nearly 3 decades of external occupation and internal power struggles have taken its toll on Afghan civilians, an estimated 8 million of which have fled the country since the Soviet invasion of 1979. Currently, the American-backed central government is too weak to extend security to the entire country. Insurgent members of the former Taliban regime and other various tribal leaders capitalize on this weakness with violent attacks, particularly in rural areas. The legacy of Islamic law, imposed by the Taliban during their rule, leaves women and children especially vulnerable in this nation.
Burma: Widespread civil war has transpired throughout Burma ever since 1948 because of persistent divisions among ethnic and political groups. Through constant fighting, civilians have been at the mercies of warring factions and of the military junta, a repressive regime currently claiming control over the country. Once marked by its thriving economy, Burma is now considered a collapsed state as the military junta continues to rule through intimidation and oppression in order to maintain the façade of control, while the civilians suffer from the scarceness of food, security, and freedom.
Colombia: Since the mid-1960s, Colombia has been plagued with civil war between guerilla groups, paramilitary groups, and the Colombian army. The conflict has evolved around the distribution of wealth and resources, with the drug-trade industry at the center of the conflict. The constant fighting has disrupted millions of lives as civilians become targeted by the escalating conflict.
Somalia: War and internal conflict have been rife throughout the long history of Somalia, dating back to its independence in 1960. From the time the government fell in 1991, lawlessness and violence have since escalated throughout the country. With the steadfast eyes of Ethiopia fervently watching, various factions divided over political grounds eagerly fight one another to
The Echo Foundation 190 “One by One by One……..” gain authority over Somalia. Anarchy and profuse human rights abuses have uprooted hundreds of thousands of lives, leaving many Somalis struggling to care for their families and homes.
Sudan: Groups separated over ethnic and religious pretenses have left Sudan devastated by constant internal strife. Conflict between the North and South regions of Sudan have persisted since independence and, recently in the 21st century, genocide has evolved from the government’s raids on a western region in Sudan called Darfur. Civilians both in the West and South have sought refuge away from the repressive government in the North as well as splintered rebel groups who continue to upset peace and security in the lives of many Sudanese civilians.
Now, have students from each group read their card aloud to the class. Afterward, begin the role- playing activity by reading aloud the following statements. Note the action beneath each statement: 1. “In camps, refugees lack the resources to maintain hygiene. It is a luxury to have soap, clean water, or even access to proper facilities to manage human waste, such as latrines. Lack of sanitation in refugee camps is a concern for outbreaks of certain diseases like cholera or dysentery.” Have the students with a triangle symbol on top-right of their card take their seats. Tell them they represent refugees who have dysentery. 2. “About 150 million people each year develop dysentery, and about 600,000 die. Most of these deaths occur in developing countries among children under the age of five.” Have the students who are under the age of 5 take their seats. Tell them they did not survive from dysentery. 3. “Malnutrition in refugee camps is also a major health concern. As people become malnourished their immune systems become weakened, and they become more susceptible to infectious diseases, like acute respiratory infections.” Have the students with the square symbol on the top-right of their cards take their seats. Tell them they represent refugees who became malnourished and too ill to fight off diseases like pneumonia or TB. 4. “Refugees live in close quarters. With thousands of people living together it is easy for the water supply to be contaminated, especially if latrines are not restricted to a certain area. When several thousand refugees are confined to tight living spaces, the transmission of diseases like measles, dysentery, or TB can be devastating. It is recommended that refugees receive at least 3.5m² of living space per person, but in many situations families share that space.” Have the students with a sun symbol on the top-right of their cards take their seats. Tell them they represent refugees who became ill during a TB outbreak. 5. “Many diseases prevalent throughout refugee camps could easily be avoided if health resources were available. For example, vaccinating children in the camps against measles or cholera could prevent unnecessary deaths and save resources in the camps. Those saved resources could be allocated toward improving the conditions in camps, like providing additional food rations or enhancing the purification of water, instead of toward disease containment.” Have the students with the circle symbol on the top-right of their cards take their seats. Tell them they represent refugees who succumbed to measles because they were not vaccinated.
The Echo Foundation 191 “One by One by One……..”
With the remaining students still standing in front of the class, read aloud the statement below:
The remaining people standing were able to endure, for a week, the life of a refugee in a camp without becoming sick. You were able to avoid dysentery, pneumonia, TB, measles, and malnourishment. However, refugees settle in a camp much longer than a week, and you will continue to face these challenges. How many of you would like to face these odds again? If I were to reshuffle the cards and hand them out again, how many of you think you would still be standing in front of the class?
Have the remaining students take their seats; then ask them to reform groups by country. Ask each group to brainstorm ideas for improving health conditions in refugee camps based on what they just experienced. Afterward, have a class discussion about each group’s recommendations.
Answers: • Build latrines away from the water supply to prevent contamination. • Promote sanitation in the camp by teaching refugees how to purify their water. • Give refugees the resources in order to live in a sanitary environment. • Spread out the living spaces for refugees (don’t crowd them). • Increase food rations. Give more nutritional food rations. • Improve health resources for refugees: build health clinics, provide vaccines, etc.
After the class has gone over ways to improve the health of refugees in camps, ask the students who they think is responsible for providing the above to refugees. Ask how likely/easy is it for the above to occur in an emergency setting, where hundreds of thousands of refugees are fleeing a conflict zone, and need urgent help.
The Echo Foundation 192 “One by One by One……..” Identity Cards
to cook my food. worried about how I will get firewood surrounding area,becoming and I am Story Home Country Age conditions. could get a job and improve my living would be able to start my life over. I Story Home Country Age Name starvation. from rape, murder, torture, and Story Home Country Age Name refugees. Story Home Country Age Name Name the delivery. delivery a week ago, but rebels blocked supposed to There was be a food Story Home Country Age Name : 34 : 30 : 19 : 3 : 12 : Deforestation is occurring in the : If I were able to leave the camp : I wish knew a life that was free : I am one of over 400,000 Somali in the camps. : Food is scarce : Aasha ( : Aasha : Duniya ( ( : Saida : Amina ( : Bokassa (
♀ ♀ ♀ : Somalia : Somalia : Somalia : Somalia : Somalia ♀ ) ) ♂ )
)
)
○ Δ
Home Country Name Home Country Age Name Home Country Age Name Home Country Age Name Home Country Age Name Story Age be given food to survive. in the camp. I constantly worry if will Story world has ever known that fear. there. I wonder if anybody else in the the ethnic minority because I represent Story escaped from. no different from the circumstances I’d be safe, but, at times, life in a camp is Story ignored as a refugee. junta, my rights are with the Burmese asylum in seeks to be on good terms Story : 26 : 30 : 15 : 4 : 11 : I was born in a refugee camp. : I was born in a refugee camp. : I can barely stand the conditions : I fear for my life in Burma : I thought if left home would the country I sought : Because : Khalid ( : Khalid Khin : Daw Mya : Daw Than : Maung Myaing : Maung
♂ : Somalia : Burma : Burma : Burma : Burma ( ) (
♀ ♀ ( ) ) ♂ ( ) ♂
) ☼ Δ
Colombian refugees. Story Home Country Age refugees. Burmese Story Home Country Age Name survive as a refugee. there, but I don’t know how long I can I am an ethnic minority persecuted Story Home Country Age Name Name became a refugee. my country for four years before I Story Home Country Age Name Name refugees. my mom and I try to survive as a rebel group came to my village. Now, Story Home Country Age : 14 : 13 : 17 : 19 : 8 : I am one of over 500,000 : I am one of over 700,000 : If I go home will die because : I was internally displaced in : My dad was killed when a : Ma Dara ( : Ma Khin ( : Ma : Lupe ( : Javier ( ( : Mateo ♀ ♂ ♂ : Colombia : Burma : Burma : Colombia : Colombia ) ) )
♀ ♀ ) )
☼ Δ ○ ○
The Echo Foundation 193 “One by One by One……..”
me in the camp. Colombia. I have no one to take care of Story Home Country Age Afghan refugees. camp is unsettling. camp, but the sedentary lifestyle in a Story Home Country Age Name Name and I miss my friends from home. refugee is hard; I am constantly hungry Story Home Country Age Name to them. in a camp, I might have access education. At least now, healthcare and to denied access I was Shaira Law, Story: Home Country Age Name Story: Home Country Age Name : 4 : 37 : 13 : 15 : 4 : I lost my mom to a landmine in : I am thankful in a refugee : I miss my home. Life as a : Lucina ( : Lucina : Carmen ( : José ( : Naheed ( : Ghezaal ( Because I am a woman, under I am a woman, under Because I am one of over two million
♂ ) ♀ : Colombia : Colombia : Colombia : Afghanistan : Afghanistan
♀ ♀ ♀ ) )
) )
☼ ○
by the Taliban. fear I will be detained, tortured, or killed Story: Home Country Age Name into another culture. whole adult life. I just want to assimilate Story Home Country Age Name river to get my water. Story Home Country Age Name a camp. ate, but at least I can walk freely within Story Home Country Age Name cook my meals in the camp. have the energy to collect firewood to Story Home Country Age Name
: 33 : 40 : 12 : 20 : 10 : I have been a refugee for my : Twice a day I walk 3 miles to the last day I : I can’t remember : I do not know how long I will : Fatima ( : Fatima : Abdul ( : Zhora ( ( : Maleeha ( : Lmong I have yet to return home, for I ♀ ♂ : Afghanistan : Afghanistan : Afghanistan : Afghanistan : Sudan ♂ ♀ ) ) ♀
) )
)
☼ Δ Δ
Sudanese refugees. Sudanese refugees. Story Home Country Age there aren’t so many people. there aren’t so without barbed-wire fences and where outside a camp. I try to imagine place Story Home Country Age Name . of my friends died a long the way. refuge in a neighboring country. Many Story Home Country Age Name Name in a refugee camp for my safe return. wait community will act as I anxiously unsafe for me. I hope the international Story Home Country Age Name by conflict. people whose lives have been uprooted Story Home Country Age Name : 18 : 4 : 16 : 16 : 23 : I am one of over 600,000 : My mom tells me stories of life : My mom tells me : I walked over 600 miles to seek : I left my country because it was : I am one of 5 million Sudanese : Diya ( ( : Grace : Luol ( ( : Naadia : Aamira ( ♂ ♂ ♀ ) ) : Sudan : Sudan : Sudan : Sudan : Sudan ♀
)
) ♀
)
☼ ○
Resources: Amnesty International, International Rescue Committee, Refugees International, U.N. High Commissioner for Refugees, U.S. Convention for Refugees and Immigrants.
The Echo Foundation 194 “One by One by One……..” VIII. Activism
For every $1 in aid a developing country receives, over $25 is spent on debt repayment. (World Bank, 2006)
icture.
p
itol. Shared p
Ca The U.S.
Students painting Peace Corps volunteers in blackboards at Nkondo Madagascar. Public domain School in Rwinkwavu, picture. Rwanda. Photo by Echo Footsteps Ambassadors.
Thai air force officers load food aid including rice, water, instant noodles and medical supplies for victims of cyclone Nargis in Burma. From the EPA/Rungroj Yongrit.
Every five seconds, a child dies because she The world’s deadliest “animal” is considered or he is starving. (FAO, 2006) to be the mosquito. (LiveScience, 2008)
The Echo Foundation “One by One by One……..” Fundraising Ideas
Need funding to start up an organization? Interested in collecting donations? Here are three fundraising websites to acquaint you with the ins and outs of fundraising—from car washes and bake sales to fairs and grants.
1. Fundraising Ideas & Products Center This site has a plethora of fun, unconventional fundraisers. “Kiss the Cow” fundraiser, anyone? http://www.fundraising-ideas.org/DIY/index.html
2. Fundraiser Insight This site and the one above are extensions of each other: Both have loads of fundraising ideas that are unorthodox and fun. However, Fundraiser Insight has the added bonus of articles to help get you started. http://www.fundraiserinsight.org/ideas
3. USA Fundraising This site has tons of fundraising ideas, too, but it also contains particularly insightful articles, some of which introduce you to the world of grants. www.usafundraising.com.
This year’s Echo Footsteps Ambassadors raised nearly $20,000 for Nkondo School, Rwanda.*
Here are some of the ways:
• Email/letter-writing campaign • Presentations to local businesses (many of which resulted in matching contributions from the company) and synagogues/churches • School carnival, tennis tournament, and “butlering” for other students and teachers • “Running for Rwanda” (donors pay for number of miles student runs) • Articles in neighborhood newsletters • Fundraising social
* Please refer to p. 175 for more information about Nkondo School and Echo’s work there.
The Echo Foundation 196 “One by One by One……..” “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.” -Margaret Mead
Every person has the potential to have a positive impact on the world today; all it takes is a little passion, Local Action initiative, and determination. Get Amnesty International involved with your school, your (What Can You Do) community, your government, and www.amnestyusa.org your world. Face AIDS www.faceaids.org Habitat for Humanity www.habitatcharlotte.org Metrolina AIDS Project
www.metrolinaaidsproject.org
Health Clinics and Hospitals Red Cross Charlotte Community Health Clinic www.redcrosshelps.org www.mycchc.com Salvation Army Volunteer Carolinas Medical Center Hospitals www.salvationarmyusa.org Networks www.carolinasmedicalcenter.org The Echo Foundation Do Something Presbyterian Hospital www.echofoundation.org www.dosomething.org www.presbyterian.org Global Volunteer Worldwide Volunteer Network Action www.volunteer.org.nz Awards Americorps Network for Good Coca-Cola Scholars Foundation www.americorps.gov www.networkforgood.org www.coca-colascholars.org Global Service Corps Idealist President’s Volunteer Service Awards www.globalservicecorps.org www.idealist.org www.presidentialserviceawards.gov Habitat for Humanity VolunteerMatch Prudential Spirit of the Community International www.volunteermatch.org Service Award www.habitat.org Youth Service www.prudential.com/spirit Peace Corps America Young Heroes of Hope Award www.peacecorps.gov www.ysa.org Contact Echo for more details. Free Rice Internships www.freerice.com Bank of America Student Leader www.bankofamerica.com/neistudentleaders Legislative Action in Progress– PIH Institute for Health and Social Justice www.opencongress.org Summer Internship Program African Health Capacity Act 2007 www.pih.org/youcando/internships.html (H.R. 3812/ S.805) Project Vote Smart National Internship Global Poverty of 2007 www.votesmart.org/program_internships.php (S.2433) The Echo Foundation Summer Internships [see “Write to Your Politicians,” p. 199] Contact Echo for more details. United States Senate Youth Program www.hearstfdn.org/ussyp
The Echo Foundation 197 “One by One by One……..” Help Fight Childhood Malnutrition
Plumpy’nut, a Ready-to-Use Therapeutic Food (RUTF), is a revolutionary product used to treat severe malnutrition. It is produced locally in Ethiopia, Democratic Republic of Congo, Niger, and Malawi. In addition to the local production sites, organizations like Médecins Sans Frontières, International Medical Corps, Save the Children, and Project Peanut Butter distribute RUTF in emergency malnutrition settings. Help fight malnutrition by donating to these programs. Plumpy’nut Sites Project Peanut Butter has established feeding programs in Sierra Leone and Malawi. At their website you can directly purchase RUTF for a child. www.projectpeanutbutter.org
Save the Children The United Kingdom chapter offers “plumpy’nut for a week” or “plumpy’nut for a month” gift donations. http://savethechildren.sandbag.uk.com From Plumpynut in the Field. Médecins Sans Frontières (Doctors Without Borders) www.doctorswithoutborders.org
International Medical Corps www.imcworldwide.org
Suggested article to read for this topic: “A Lifesaver Called ‘Plumpynut’” (p.121)
The Echo Foundation 198 “One by One by One……..” Write to Your Politicians
Five Tips on Constructing a Letter/Email to Your Politician 1. Introduce who you are. 2. Keep your letter focused on one specific topic. 3. Keep your letter factual (not emotional) and concise (approximately one page). 4. Request the action you would like the politician to take. 5. Maintain a professional and respectful tone in your letter.
Sample Letter
[Date] 7/12/08
[Recipient’s title and name] The Honorable Richard Burr Both a Senator’s and a Representative’s title in an address is United States Senate “The Honorable.” 217 Russell Senate Office Building [Recipient’s Address] Washington, D.C. 20510
Dear [Recipient’s title and last name],* Dear Senator Burr, *i.e. Representative (last name), Governor (last name), Senator (last name), or Mr. President (no last … name). …
… … Sincerely,
Joe Smith
How to Contact Your Politicia 0123 Tolley Drive Sincerely, Charlotte, NC 28204 [Sender’s Name] Email: [email protected] Phone: 999-999-9999 [Sender’s address/contact information]
Find a Politician at Congressional Directory www.congress.org
Sample formats for addresses:
North Carolina Representative North Carolina Governor The President The Honorable (First and Last Name) Governor (First and Last Name) President (First and Last Name) United States House of Representatives Office of the Governor The White House (Insert Street Address) 20301 Mail Service Center 1600 Pennsylvania Avenue NW Washington, D.C. 20515 Raleigh, NC 27699 Washington, D.C. 20500
The Echo Foundation 199 “One by One by One……..”
The Echo Foundation 200 “One by One by One……..”
IX. Appendix
The Echo Foundation “One by One by One……..” Glossary of terms referenced throughout the curriculum guide
General Definitions
Antiretrovirals (ARVs)—www.who.org
Antiretroviral drugs inhibit the replication of HIV and delay the deterioration of the immune system, so as to increase survival and improve quality of life for HIV/AIDS patients.
Gross Domestic Product (GDP)—www.investopedia.com
Gross domestic product is the monetary value of all the finished goods and services produced within a country’s borders in a specific time period. GDP is used as an indicator of a country’s economic health and standard of living.
GDP = C + G + I + NX C = all private consumption, or consumer spending, in a nation’s economy G = the sum of government spending. I = the sum of all the country’s businesses spending on capital. NX = the nation’s total exports, calculated as total exports minus total imports. (NX = Exports – Imports)
Gross National Product (GNP)—www.investopedia.com
Gross national product is an economic statistic that includes GDP, plus any income earned by residents from overseas investments, minus income earned within the domestic economy by overseas residents. GNP is a measure of a country’s economic performance, or what its citizens produced (i.e. goods and services) and whether they produced these items within its borders.
Highly Active Antiretroviral Therapy (HAART)—www.globalhealthreporting.org
It is the combination of at least three antiretroviral (ARV) drugs that attack different parts of HIV or stop the virus from entering blood cells. Even among people who respond well to HAART, the treatment does not get rid of HIV. The virus continues to reproduce, but at a slower pace.
Diseases
Cholera—www.cdc.gov
Cholera is an acute, diarrheal illness caused by infection of the intestine. The infection is often mild or without symptoms, but sometimes it can be severe. Approximately one in 20 infected persons has severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps, which lead to rapid dehydration and shock. Without treatment, death can occur within hours.
The Echo Foundation 202 “One by One by One……..” Guinea Worm Disease—www.dhpe.org
Guinea worm disease is a parasitic worm infection that occurs mainly in Africa. People get infected when they drink standing water containing a tiny water flea that is infected with the even tinier larvae of the Guinea worm. Inside the human body, the larvae mature, growing as long as 3 feet. After a year, the worm emerges through a painful blister in the skin, causing long- term suffering and sometimes crippling after-effects.
HIV/AIDS—www.mayoclinic.com
AIDS is a chronic, life-threatening condition caused by the human immunodeficiency virus (HIV). By damaging or destroying the cells of your immune system, HIV interferes with your body’s ability to effectively fight off viruses, bacteria and fungi that cause disease. This makes you more susceptible to certain types of cancers and to opportunistic infections your body would normally resist, such as pneumonia and meningitis.
Malaria—www.medicinenet.com
Malaria is an infectious disease caused by a parasite, Plasmodium, which infects red blood cells. Malaria is characterized by cycles of chills, fever, pain and sweating. Historical records suggest malaria has infected humans since the beginning of mankind. The name “mal ‘aria” (meaning “bad air” in Italian) was first used in English in 1740 by H. Walpole when describing the disease.
Opportunistic Disease/Infection—www.thebody.com
An opportunistic disease is a disease that will most often make you sick given the “opportunity” of a damaged or weakened immune system (e.g. because of AIDS, cancer); generally speaking, if you are exposed to an opportunistic disease, and you have a fully-functioning immune system, these illnesses will cause few, if any symptoms, because a healthy immune system is able to successfully fight off the disease or keep it under control.
Polio—www.polioeradiction.org
Poliomyelitis (polio) is a highly infectious viral disease. It invades the nervous system, and can cause total paralysis in a matter of hours. The virus enters the body through the mouth and multiplies in the intestine. One in 200 infections leads to irreversible paralysis (usually in the legs). Amongst those paralysed, 5%-10% die when their breathing muscles become immobilized. Polio can spread widely before cases of paralysis are seen—as most people infected with poliovirus have no signs of illness, they are never aware they have been infected.
Schistosomiasis—www.cdc.gov
Schistosomiasis, also known as bilharzia, is a disease caused by parasitic worms. Infection occurs when your skin comes in contact with contaminated freshwater in which certain types of snails that carry schistosomes are living. Schistosoma parasites can penetrate the skin of persons who are wading, swimming, bathing, or washing in contaminated water. Within several weeks,
The Echo Foundation 203 “One by One by One……..” worms grow inside the blood vessels of the body and produce eggs. Some of these eggs travel to the bladder or intestines and are passed into the urine or stool. Schistosomiasis is not found in the United States, but more than 200 million people are infected worldwide.
Tuberculosis—www.cdc.gov
Tuberculosis (TB) is a disease caused by germs spread from person to person through the air. TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. In most cases, TB is treatable; however, persons with TB can die if they do not get proper treatment.
Multi-Drug Resistant Tuberculosis (MDR-TB)
MDR-TB is TB that is resistant to at least two of the best anti-TB drugs: isoniazid and rifampicin [rifampin]. (These drugs are considered first-line drugs used to treat all persons with TB.)
Extensively Drug Resistant Tuberculosis (XDR-TB)
XDR-TB is a relatively rare type of MDR-TB. XDR-TB is defined as TB which is resistant to isoniazid and rifampin as well as fluoroquinolone and at least one of three injectable second-line drugs (amikacin, kanamycin, or capreomycin). Because XDR-TB is resistant to first-line and secondline drugs, patients are left with treatment options that are much less effective.
Organizations
Centers for Disease Control and Prevention (CDC)—www.worldbookonline.com
The Centers for Disease Control and Prevention is an agency within the United States government’s Department of Health and Human Services. Established in 1946, it works to protect public health by administering national programs for the prevention and control of disease and disability.
Doctors Without Borders/Médecins Sans Frontières (MSF)— www.worldbookonline.com
Doctors Without Borders/Médecins Sans Frontières is an independent nongovernmental organization (NGO). Established in 1971 by a group of French doctors (including Bernard Kouchner), it sends medical personnel, medical supplies, food, fresh water, and other necessities to regions of the world where people are at risk from war, disease, or natural disasters.
The Echo Foundation 204 “One by One by One……..” Bill and Melinda Gates Foundation—www.worldbookonline.com
The Bill and Melinda Gates Foundation is an independent nongovernmental organization (NGO). Established in 2000 by Bill Gates, chairman of Microsoft Corporation, and his wife, Melinda, it funds a variety of programs that seek to improve the health, education, and well-being of people in the United States and in other countries.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria
Founded in 2002, the Gobal Fund is a public/private partnership between the private sector, governments, and international aid agencies that collects funds to target AIDS, TB, and malaria. Unlike the IMF, it does not give out loans, but only grants; and unlike the WHO, it does not oversee implementation efforts, but is a purely financial organization to organize cash to donate to the most promising aid initiatives.
International Monetary Fund (IMF)—www.worldbookonline.com
The International Monetary Fund is an United Nations agency. Established at the Bretton Woods Conference in 1944, it oversees member nations’ macroeconomic policies (e.g. exchange rates, trade). Unlike the World Bank, it is a lender of last resort, meaning that it is willing to provide loans to nations that are unable to obtain loans elsewhere. To that end, it provides short-term loans and policy advice to its more than 186 member nations (developed and developing countries alike). By lending money to a member, the IMF reassures private banks and investors that it is safe for them to put money in the country.
Joint United Nations Programme on HIV/AIDS (UNAIDS)
The Joint United Nations Programme on HIV/AIDS is a collaboration between 10 United Nations agencies. Established in 1994, it is charged with controlling the global AIDS epidemic and advocating on behalf of people living with HIV/AIDS.
Médecins Sans Frontières (MSF)—see “Doctors Without Borders”
National Institutes of Health (NIH)—www.worldbookonline.com
The National Institutes of Health is an agency within the United States government’s Department of Health and Human Services. Established in 1887, NIH funds and conducts biomedical research.
Organisation for Economic Cooperation and Development (OECD)
The Organisation for Economic Cooperation and Development is an organization of nations. Established in 1948 to facilitate the Marshall Plan, it is now a setting for its 30 member nations and more than 100 nonmembers (developed and developing countries alike) to compare policy, identify best practices, and seek answers to common difficulties.
The Echo Foundation 205 “One by One by One……..” United Nations (UN)—www.worldbookonline.com
The United Nations is an international organization of nations. Established in 1945 after WWII to replace the defunct League of Nations, it works for world peace through global cooperation in international law and security as well as promotion of economic development and human rights. Almost all of the world’s independent countries—192 of them—belong to the UN.
UNAIDS—see “Joint United Nations Programme on HIV/AIDS”
United States Agency for International Development (USAID)— www.worldbookonline.com
The United States Agency for International Development is an independent agency within the United States government. Established in 1961 to administer the Marshall Plan, it is responsible for coordinating the nation’s humanitarian, economic, and technical foreign aid programs.
The World Bank—www.worldbookonline.com
The World Bank is a United Nations agency. Established at the Bretton Woods Conference in 1944, it provides long-term loans to governments and private contractors for infrastructure and economic projects in developing nations.
World Food Program (WFP)/ Food and Agriculture Organization (FAO)/ International Fund for Agricultural Development (IFAD)—www.wfp.org
Within the UN family, the mandates of the three agencies—WFP, FAO, and the IFAD— complement one another. Founded in 1960, 1945, and 1977, respectively, each works to fulfill the World Food Summit’s aim of eradicating global hunger and poverty: WFP with food aid, FAO through its technical expertise in agriculture and IFAD via international financial assistance.
World Health Organization (WHO)—www.worldbookonline.com
The World Health Organization is a United Nations agency. Established in 1948, it coordinates global action against infectious diseases, helps build better health systems, establishes best practices throughout the world, and promotes disease prevention through collaborating with governments to provide safe drinking water, sewage disposal, and vaccinations.
World Trade Organization (WTO)—www.worldbookonline.com
The World Trade Organization is an international organization that includes most of the nations in the world. Established in 1995, it promotes fair trade practices among nations and mediates disputes between member nations.
The Echo Foundation 206 “One by One by One……..” Initiatives
Abuja Declaration—www.africarecovery.org
Signed in April 2001, the Abuja Declaration saw African leaders declare AIDS in “a state of emergency in the continent” and renew pledges to fight against HIV/AIDS, TB, and related infectious diseases.
The Africa “15% Now!” Campaign—www.africa15percentcampaign.org
The Africa “15% Now!” Campaign is the flagship campaign of the Africa Public Health Rights Alliance [APHRA—an nongovernmental organization (NGO)] with the objective of advancing health rights and health development through actualizing the African Union (AU) Abuja pledge for AU member states to allocate at least 15% of national budgets to health.
African Health Capacity Act of 2007 (H.R. 3812 /S.805)—www.opencongress.org
The African Health Capacity Act is a United States Congressional bill to assist sub-Sahara African countries in improving medical facilities and retaining medical workers so as to achieve international goals in treating/preventing major diseases and reducing maternal and child mortality.
Cambridge Declaration—www.ghdonline.org
Signed in June 2008, in Cambridge, Massachusetts, the Cambridge Declaration saw stakeholders from communities, nongovernmental organizations (NGOs), governments, donors, industry, and academia declare the formation of a movement to identify best practices in treating drug-resistant tuberculosis so as to increase access to treatment.
Clinton-Hunter Development Initiative (CHDI)—www.clintonfoundation.org, www.clintonpresidentialcenter.org
Launched in 2006, the Clinton-Hunter Development Initiative is a collaboration of the Clinton Foundation and the Hunter Foundation to catalyze sustainable economic growth in Africa (it currently works in Malawi and Rwanda). To this end, it strengthens agriculture, helps develop agri-businesses, and increases access to clean water, quality healthcare, and education in ways that can be locally sustained.
Doha Declaration
Signed in November 2001 and adopted by the World Trade Organization (WTO) Ministerial Conference of the same year, the Doha Declaration reaffirmed the right of governments to circumvent drug patent rules in order to provide drug access for all.
The Echo Foundation 207 “One by One by One……..” HIV Equity Initiative—www.pih.org
Launched by Partners In Health in 1998, the HIV Equity Initiative to provide free antiretroviral (ARV) therapy to a handful of AIDS patients, using a community-based model that trains and employs local Haitians to administer medications daily and provide social support. This was the world’s first program to provide free, comprehensive HIV care and treatment in an impoverished setting and has been replicated in impoverished regions throughout the world.
Medicaid—www.worldbookonline.com
Launched in 1965, Medicaid is a United States government program that works in cooperation with state governments to finance medical assistance to low-income families and individuals.
Medicare—www.worldbookonline.com
Launched in 1965, Medicare is a United States government health insurance program that covers nearly all people age 65 or older.
Millennium Development Goals (MDGs)—www.un.org/millenniumgoals
Established in 2000, the eight Millennium Development Goals are benchmarks that 189 United Nations member nations have pledged efforts to meet by 2015. They are as follows: 1. To eradicate extreme poverty and hunger 2. To achieve universal primary education 3. To promote gender equality and to empower women 4. To reduce child mortality 5. To reduce maternal mortality 6. To halt and reverse the spread of HIV/AIDS, malaria, and other major diseases 7. To ensure environmental sustainability, halve the proportion of people without access to safe drinking water, and improve slum conditions 8. To develop a rule-based trading and financial system, as well to implement sympathetic economic policies (e.g. elimination of tariffs) and to increase access to drugs and technology for least developed countries.
President’s Emergency Plan for AIDS Relief (PEPFAR)—www.pepfar.gov
Launched in 2003 by the United States, the President’s Emergency Plan for AIDS Relief is the largest commitment ever by any nation for an international health initiative dedicated to a single disease: a five-year, $15 billion, multifaceted approach to combating HIV/AIDS around the world.
The Echo Foundation 208 “One by One by One……..” Resources
Online Resources The Global Fund To Fight AIDS, Tuberculosis and Malaria Amnesty International www.theglobalfund.org www.amnesty.org United Nations Avert www.un.org www.avert.org U.S. Committee for Refugees and BBC News Immigrants news.bbc.co.uk www.refugees.org
Centers for Disease Control and Prevention Write Your Representative www.cdc.gov www.house.gov/writerep
Doctors Without Borders World Health Organization www.doctorswithoutborders.org www.who.int/en
Human Rights Watch Print/Video Resources www.hrw.org Dr. Farmer’s Remedy for World Health CBS News/60 Minutes, 2008 (video) International Committee of the Red Cross www.icrc.org Global Health Equity: From Haiti to Rwanda Partners In Health, 2006 (video) International Rescue Committee www.theirc.org Greatest Silence: Rape in the Congo HBO Documentary Films, 2007 (video) National Institutes for Health www.nih.gov Mountains Beyond Mountains—Tracy Kidder Random House, 2004 Oxfam International www.oxfam.org State of Denial Lovett Productions, 2003 (video) Partners In Health Their Brothers’ Keepers: Orphaned by AIDS www.pih.org Green Lion Productions, 2005 (video)
Physicians for Human Rights War Against Women in Congo physiciansforhumanrights.org CBS News/60 Minutes, 2008 (video)
Project Vote Smart Materials for Educators www.votesmart.org PBS Healthcare Lesson Plans Refugees International www.pbs.org/newshour/extra/teachers/ www.refugeesinternational.org lessonplans/us/jan-june08/ miller_healthcare.html The Guardian International Development Journalism Competition United Nations CyberSchoolBus www.guardian.co.uk/developmentcompetition www.un.org/cyberschoolbus
The Echo Foundation 209 “One by One by One……..” THE ECHO FOUNDATION
presents
“One by One by One ...... ”
Paul Farmer & Partners In Health
GUIDELINES
ART & PHOTOGRAPHY CONTEST
“Beyond mountains there are mountains,” is a Haitian proverb describing the daily plight of Haitian life, or more simply describing the hardships of people who live in poverty. Thinking about the circumstances that prevent people in the world from receiving good healthcare, create a piece of artwork that conveys these challenges.
WHAT: Presented by The Echo Foundation, the “One by One by One……..” project offers contests in two categories: ART AND PHOTOGRAPHY. Students are invited to respond to the above challenge in either medium. WHO: The contest is open to all Charlotte area high school students, grades 9 – 12. WHEN: Entry forms and submissions must be postmarked or received by The Echo Foundation at 1125 East Morehead Street, Suite 106, Charlotte, NC 28204, by Friday, December 5, 2008. HOW: Entry forms may be downloaded at http://www.echofoundation.org, The Echo Foundation web site, or obtained at The Echo Foundation office. No student name should appear on the front of a submission and an entry form must accompany each entry.
PURCHASE AWARDS AND CATEGORIES: First ($100), second ($75) and third ($50) prizes will be given in each of the two categories: Art and Photography. All other Art and Photography entries can be reclaimed following the contest’s judging.
JUDGING AND RULES: Educators and professionals in the corresponding fields will serve on the judging panel. The panels reserve the right to not award a cash prize in a category if the submissions do not meet the qualifications for entry. 2-D original artwork and photography may not exceed 36” in height or width.
For more information contact: The Echo Foundation at 704-347-3844, or email questions to [email protected].
The Echo Foundation 210 “One by One by One……..” THE ECHO FOUNDATION
presents
“One by One by One ...... ”
Paul Farmer & Partners In Health
ART & PHOTOGRAPHY CONTEST: OFFICIAL ENTRY FORM
******* This completed and signed form must accompany each entry. Copies of this form are permissible.
Two-dimensional original works of art no larger than 36” x 36” will be accepted. Photographs in Black & White or Color with no size limitations will be accepted. Work that is based on published photographs by others is ineligible for competition.
Please Print or Type:
Full Name: ______Male Female
Address: ______
City: ______State: ______Zip: ______
Phone: ______Email: ______School: ______
Current Class Status: Freshman Sophomore Junior Senior
I am submitting: Art Photography
Title of entry and brief description:
______
______
I give permission for my student’s entry to be used in future publications and/or exhibits.
______Parent/Guardian Signature Date
Entry form and submission must be postmarked or received by The Echo Foundation, 1125 E. Morehead Street, Suite 106, Charlotte, NC 28204, by Friday December 5, 2008.
For more information contact: The Echo Foundation at 704-347-3844 or email questions [email protected].
The Echo Foundation 211 “One by One by One……..” THE ECHO FOUNDATION
presents
“One by One by One ...... ”
Paul Farmer & Partners In Health
GUIDELINES
ESSAY & POETRY CONTEST
Do you believe that everyone around the world, rich or poor, is entitled to healthcare?
Please respond in detail: If yes, why? If no, why not? What can you, a student in Charlotte, NC, do to help a sick person living on the other side of the world?
WHAT: Presented by The Echo Foundation, the “One by One by One……..” project offers writing contests in two categories: ESSAY AND POETRY. Students are invited to respond to the above challenge in either category. WHO: The contest is open to all Charlotte area high school students, grades 9 – 12. WHEN: Entry forms and submissions must be postmarked or received by The Echo Foundation at 1125 East Morehead Street, Suite 106, Charlotte, NC 28204, by Friday, December 5, 2008. HOW: Entry forms may be downloaded at http://www.echofoundation.org, The Echo Foundation web site, or obtained at The Echo Foundation office. No student name should appear on the front of a submission and an entry form must accompany each entry.
PURCHASE AWARDS AND CATEGORIES: First ($100), second ($75) and third ($50) prizes will be given in each of the two categories.
JUDGING AND RULES: Educators and professionals in the corresponding fields will serve on the judging panel. The panels reserve the right to not award a cash prize in a category if the submissions do not meet the qualifications for entry. All written entries must be typed (double-spaced). Word limit for essays is 1,500; poetry has no limit on length.
For more information contact: The Echo Foundation at 704-347-3844, or email questions to [email protected].
The Echo Foundation 212 “One by One by One……..” THE ECHO FOUNDATION
presents
“One by One by One ...... ”
Paul Farmer & Partners In Health
ESSAY AND POETRY CONTEST: OFFICIAL ENTRY FORM
******* This completed and signed form must accompany each entry. Copies of this form are permissible.
Essays may be no more than 1,500 words, must be printed in size 12 font and double-spaced.
Please Print or Type:
Full Name: ______Male Female
Address: ______
City: ______State: ______Zip: ______
Phone: ______Email: ______School: ______
Current Class Status: Freshman Sophomore Junior Senior
I am submitting: Essay Poetry
Title of entry and brief description:
______
______
I give permission for my student’s essay entry to be used in future publications and/or exhibits.
______Parent/Guardian Signature Date
Entry form and submission must be postmarked or received by The Echo Foundation, 1125 E. Morehead Street, Suite 106, Charlotte, NC 28204, by Friday, December 5, 2008.
For more information contact: The Echo Foundation at 704-347-3844 or email questions to [email protected].
The Echo Foundation 213 “One by One by One……..” THE ECHO FOUNDATION ______
AN INTRODUCTION
On March 12, 1997, as the focus of the community-wide, year-long, educational Elie Wiesel Project, internationally revered humanitarian and Nobel Laureate for Peace, Elie Wiesel spoke “Against Indifference” to over 23,000 students and adults. He was so inspired by this visit to Charlotte, that, as he left, he challenged the community to continue its focus on the critical issues of human dignity, justice and moral courage. He offered seed money and his wholehearted assistance in obtaining speakers and developing programs to address these issues. Thus The Echo Foundation was born, and with it its mission: …to sponsor and facilitate those voices that speak of human dignity, justice and moral courage in a way that leads to positive action for humankind. The mission is implemented by bringing speakers, exhibitions and performances to the Charlotte Region as catalysts for educational programs. For each project school-based curriculum materials that meet national and international standards are developed and made available free of charge to schoolteachers across the region.
Our goals are: A. Educating for compassion, justice and moral decision making; B. Teaching understanding through fostering relationships founded in respect; C. Facilitating opportunities to act against indifference on these issues.
Our region has demonstrated a need and a desire to address issues of racial diversity, culture and the quality of human existence. The Echo Foundation brings together people from all corners of Charlotte-Mecklenburg to address these vital goals through student dialogues, teacher workshops, theatrical productions, lectures and more. The primary focus of all projects is humanity. The secondary focus is specific to the particular speaker, exhibition or performance. For example, the primary focus of The Elie Wiesel Project: Against Indifference was justice and world peace; the secondary focus of the Project was World War II and the Holocaust.
The Echo Foundation’s recent and current projects include the production of the play, The White Rose; The Varian Fry Exhibition Project; The Harry Wu Project; Living Together in the 21st Century, with Jonathan Kozol; the Kerry Kennedy Project: For Human Rights; The Wole Soyinka Project: Truth Memory and Reconciliation; Syl Cheney-Coker Project: Free to Write; The Jeffrey Sachs Project: Environment, Poverty and Healthcare on a Global Scale: What can one person do?; Considering Social Capital with Henry Louis Gates, Jr.; Bernard Kouchner: Compassion Without Borders; A Gathering of Nobel Laureates: Science for the 21st Century; ECHO RETURNS: Young Heroes of Hope; our 10th Anniversary project, A Decade Inspired by Elie Wiesel; and most recently, From Rwanda to Darfur: A Week of Hope & Reconciliation.
The Echo Foundation is governed by an International Board of Advisors and a Charlotte Board of Trustees. Mr. Wiesel is an active Honorary Chairperson who continues to meet with Echo on a regular basis. To date, many outstanding professionals in the community have offered their services to The Foundation pro bono. The corporate, religious and educational communities have generously exhibited their support of Echo’s mission and projects.
The Echo Foundation 214 “One by One by One……..” THE ECHO FOUNDATION ______
- International Board of Advisors -
Elie Wiesel, Honorary Chairperson Nobel Laureate for Peace, 1986
Henry Louis Gates, Jr., Chair, Department of African & African American Studies, Harvard University Kerry Kennedy, International Human Rights Activist and Author Dr. Bernard Kouchner, Founder, Doctors Without Borders Jonathan Kozol, Child Advocate Jeffrey D. Sachs, Director, The Earth Institute, Columbia University Harry Wu, Executive Director, The Laogai Research Foundation
- Charlotte Board of Advisors -
Alan Dickson, President, The Dickson Foundation Clarice Cato Goodyear, Community Volunteer The Honorable James Martin, Vice President for Research, Carolinas HealthCare System Sally Robinson, Community Volunteer Bill Vandiver, Retired Executive, Bank of America The Honorable Melvin Watt, United States Congressman, North Carolina Dr. James H. Woodward, Chancellor Emeritus, University of North Carolina at Charlotte
- Board of Trustees -
Thomas Pollan, Chairperson CEO, Pollan Enterprises Stephanie G. Ansaldo, President The Echo Foundation The Honorable Kurt Waldthausen, Secretary Owner, Waldthausen & Associates, Inc. Thom Young, Treasurer Managing Principal, Optcapital Ambassador Mark Erwin, Chairman Emeritus President, Erwin Capital
*Dr. Yele Aluko, Mid Carolina Cardiology Joseph F. Andolino, VP of Business Development and Tax, The Goodrich Corporation Frank L. Bryant, Partner, Poyner & Spruill, LLP Curt C. Farmer, Director for the Carolinas, Wachovia Wealth Management Arthur J. Gallagher, President, Charlotte Campus, Johnson & Wales University Dr. Joan Lorden, Provost, University of North Carolina at Charlotte *James Y. Preston, Esq., Partner, Parker, Poe, Adams & Bernstein *Kathy Rowan, Senior Public Relations Counselor, Corder Philips Jack Stroker, Partner, L & J Associates Eulada Watt, Office of Research, University of North Carolina at Charlotte Gail Brinn Wilkins, ASID, President, Gail Brinn Wilkins, Inc.
* Denotes membership on Executive Committee. The Echo Foundation 215 “One by One by One……..”