Category Archives: Health Rights

Louisiana: High Rhetoric on Ebola, Low Concern for Public Health

The 63rd Annual Meeting of the American Society for Tropical Medicine and Hygiene begins in a couple days in New Orleans Louisiana. In preparation for this event the Governor of Louisiana through the Department of Health and Hospitals dis-invited any conference participant who has been to an Ebola-affected country (Liberia, Guinea, Sierra Leone) with the following information:

Lousiana StateNOTICE TO TRAVELERS: From a medical perspective, asymptomatic individuals are not at risk of exposing others; however, the State is committed to preventing any unnecessary exposure of Ebola to the general public. As part of that commitment, we have requested that any individuals that will be traveling to Louisiana following a trip to the West African countries of Guinea, Liberia, and Sierra Leone or have had contact with an EVD-infected individual remain in a self-quarantine for the 21 days following their relevant travel history. In Louisiana, we love to welcome visitors, but we must balance that hospitality with the protection of Louisiana residents and other visitors.

Not only does this decision, which bars many people who had no contact with patients or infected people, lack scientific backing, it is also unlikely to do much for health of Louisiana. These citizens actually need more that fearful proclamations to protect them. Louisiana needs to step up its public health efforts to show it really cares about its residents instead of political grandstanding.

America's Health RankingsAmerica’s Health Rankings from the United Health Foundation presents some interesting information on each US state – not just its ranking overall, but factors that contribute to this ranking. Overall, Louisiana ranked 48th in 2013. While there are 30 key indicators, ranks on individual vary with 24 being negative and 6 having a positive influence in the Louisiana’s overall 2013 rankings. Some problem areas are noted below:

  • Obesity 50th
  • Smoking 46th
  • High School Graduation 46th
  • Low Birth Weight 49th
  • Infant Mortality 48th
  • Infectious Disease 48th
  • Preventable Hospitalizations 48th

Of particular interest is public expenditure to address health problems. Here Louisiana ranks 19th at $87 per capita, below the national average. “After 4 years of increases, public health funding (in Louisiana) declined in the past year,” according to America’s Health rankings.

Nationally, “Public health funding ranges from more than $200 per person in Alaska and Hawaii to $37 per person in Nevada. The average funding in the United States is $92 per person, unchanged from last year’s edition (2012).” Louisiana, while not the lowest spender, could certainly do more to bring itself up in the rankings and help its people.

We would understand Louisiana’s concern if it had done more to correct these low rankings. The State’s neglect of its citizens is more of a threat to public health than a visiting conference attender who may have tried to improve public health in Africa.

Elephants Fight, Aid Cut, Grass Suffers

DSCN6435The impact of the international response to Uganda’s any-gay laws is starting to be seen. IRIN estimates that 37% of Uganda’s annual health budget is dependent on development aid from outside. So far, “Project and budget support worth about US$140 million has been suspended or redirected by the World Bank, US and several European countries, including Sweden, the Netherlands, Norway and Denmark,” which represents about half or 20% of the health budget.

IRIN shares the concerns of a senior Ugandan official who explains that, “We have a crisis. The government has been forced to review its priorities and make readjustments as donors have withheld aid. We are seeing stagnation of social services and public investments. The civil servants have not been paid their salaries [in February].” Even AIDS activists are concerned about the humanitarian impact of such suspensions.

While the situation certainly bodes ill for people with AIDS, TB, malaria and other health problems, it more than demonstrates the difficulties when national health and development budgets are dependent on outside resources.  World Malaria Day for 2014 continues with the previous theme of investing in malaria. Clearly when countries won’t or can’t direct their own national resources to health, the population will suffer.

Even without the political strings attached to aid, aid is not sustainable in the long run. Industrialized countries, through bilateral and multilateral contributions and their citizens, through NGOs, not only grow fatigued, but also run short of funds.

Uganda is entering the realm of oil producing nations. Hopefully more resources will in fact be available, unless the country follows the example of other oil nations where more oil funds wind up in Swiss banks than in health and social services.

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IRIN has been a strong source of news and information for our postings. Please look at the new posting on IRIN’s website concerning its future. “You may have seen some public discussion recently about IRIN’s future, arising most recently from this online petition, an independent initiative launched by a US-based reader last week. In the interest of clarity we are taking this opportunity to let you know ourselves what is happening. Full report.”

Malaria Elimination in a Challenging Human Rights Environment

A new article by Wickramage and Galappaththy raises numerous challenges facing a country like Sri Lanka that is approaching malaria elimination.  Human trafficking takes people from a malaria free zone, transits them through malarious areas in West Africa, and then in this case they are rescued and returned home, some carrying malaria parasites.

the-spatial-limits-of-malaria-transmission-maps-in-sri-lanka-2010-sm.jpgOther island nations are also addressing the problem of preventing future reintroduction of malaria, but they are not in a post-conflict situation that creates what Wickramage and Galappaththy euphemistically called “irregular migrants.” Seychelles has addressed both vector control as well as provision of malaria chemoprophylaxis and health education to outbound citizens.

Trafficked citizens would obviously and unfortunately miss the opportunity to get prophylaxis (as well as many other opportunities in life).  In Sri Lanka those returning from trafficking transit in West Africa were screened at the airport and treated. Seychelles could learn from this experience.

Mauritius has not had an indigenous malaria case in over a decade although the vectors are still present. Mauritius actively screens people return from malaria endemic areas at both airport and seaport.

Malaria Journal reports that in Sao Tome and Principe “A steep decline of ca. 95% of malaria morbidity and mortality was observed between 2004 and 2008 with use of the combined control methods. Malaria incidence was 2.0%, 1.5%, and 3.0% for 2007, 2008, and 2009, respectively. In April 2008, a cross-sectional country-wide surveillance showed malaria prevalence of 3.5%, of which 95% cases were asymptomatic carriers.”

So yes, countries approaching elimination must have a surveillance system that finds both obvious clinical cases as well as asymptomatic infections among residents and people returning to or visiting from the outside.  Island nations are among the first to put this process to the test.  But the bigger lesson from Sri Lanka’s ‘irregular migrants’ is that as long as conflicts, human trafficking and human rights violations persist, malaria will be difficult to eliminate.  Malaria demonstrates that no man or woman is an island.

What’s in a Lifestyle?

The coverage has started of the big UN focus on non-communicable diseases (NCDs).  BBC leads with a headline that states, “WHO targets non-communicable ‘lifestyle’ diseases.” Lifestyle is a facile term that may lead one to think that people have certain diseases because of choices in their lifestyle.

Is poverty a lifestyle? We doubt whether people chose poverty.

NCDs, like almost all diseases, have a ‘behavioral component’ in their etiology, but we need to be careful not to blame the victim whose health related behavior may be confined by culture, poverty or a political system.  Behavior also therefore is not a simple matter of ‘lifestyle.’

So, if we are getting into the issue of behavior as a factor in the spread of disease, we need to be careful about making black and white distinctions between communicable and non-communicable.  Malaria, a communicable disease (with a vector) arises not from simple lifestyle choices to avoid sleeping under an insecticide treated – the factors influencing behavior are complex. Furthermore, communicable diseases have non-communicable consequences – witness the challenges of chronic anemia and neurological consequences of malaria.

In the push for a new theme for the decade we need to avoid compartmentalization and remember the universal goals that launched primary health care in 1978.  Our goal should not be to focus on or un-neglect a class of diseases, but to ensure all people, especially those living in poverty, have equitable access to whatever care and prevention they need.

If Myanmar cannot control malaria, what of Burma?

Myanmar has operated only three Global Fund Grants in its history. The Round 3 Malaria grant was terminated at Phase 1 in 2007. Two million dollars was disbursed, but no results were found in the progress report at the Global Fund website. No explanatory notes were offered.

In the meantime, malaria continues unabated. Reports from a remote rural area observe that, “About half of the villagers in this remote corner of Kachin State are suffering from the mosquito-borne disease, but medical supplies provided by the Kachin Baptist Convention (KBC), a Christian group, ran out two weeks ago.”

The website explains that villagers are reluctant to complain because, “In military-ruled Myanmar, saying anything seen as critical of the authorities can have serious consequences.” Instead villagers wait as they lack money needed to reach clinics and thus, resort to indigenous treatments.

Reports from the KBC indicate that they only had the resources to assist about five percent of the Kachin population in the fight against malaria. The mission group complained that, “There are many people we can’t reach, and it’s getting worse. It’s linked to poverty. Most of them can’t even afford mosquito nets.”

Myanmar does have an unsigned Round 9 malaria Global Fund grant pending. One wonders whether performance would be any better than Round 3.

Myanmar is part of the broader Mekong area where fears of malaria drug resistance are a constant concern. IRIN reports that, “Mekong countries of Cambodia, China, Lao PDR, Myanmar, Thailand and Vietnam, show (malaria drug) tolerance … with the drug proving less effective and taking longer than previously to kill the parasite.”

IRIN noted that, “… studies in Myanmar had shown that parasites were still detected in some cases after treatment, taking more than a benchmark three days to be cleared …  This is an indication that there is resistance .” Furthermore, “only around 500,000 ACT courses are available annually – a fraction of what is needed to treat an estimated 8.5 million malaria cases.”
wikimedia-commons-myanmar.jpgAccess to malaria treatment and prevention is not a unique problem. IRIN reminds us that in the wake of a major tropical cyclone in 2008 the Myanmar population in affected areas was threatened with malnutrition and diseases due to lack of adequate access to food and medicine. This health neglect is endemic.

Will new elections help? BBC reports that a group of 15 nations, “known as the Friends of Burma, called for inclusive, participatory and transparent elections. Afterwards the secretary general said he had expressed concern that conditions in Burma do not measure up to what is needed for an inclusive political process.”

Without an inclusive political culture can the political will and accountability exist to control and eventually eliminate malaria? This is not just an issue for the poor and suffering within Myanmar since practices there enhance malaria drug resistance in the region and ultimately the world.  If Myanmar cannot control malaria, one wonders if Burma could.

Workplace health – what is feasible?

girl-selling-ingredients-2.jpgNigeria’s Daily Champion Newspaper reports that, “CHIEF Executive Officer of Friends of the Global Fund Africa (Friend Africa)- an advocacy and fund raising organization, Akudo Anyanwu Ikemba has canvassed the need for institutionalize workplace policies to ensure the protection of health and right of workers.”

Participants at the 2-day Workplace Policy Workshop recognized that, “The HIV/AIDS scourge, tuberculosis and malaria are impending threats to productivity that could have negative economic impact on the workforce if not properly tackled.”  Akudo Ikemba also explained that “there is need for Small and Medium Enterprises (SMEs) to embark on deliberate workplace policies.”

In reality ‘small’ enterprises does not begin to describe the work setting for the majority of people in Nigeria and Africa generally. “This sector may be invisible, irregular, parallel, non-structured, backyard, under ground, subterranean, unobserved or residual.” It is hard to imagine members of this sector setting workplace health policies.

Their numbers are substantial. Geoffrey Nwaka estimates that the sector accounts for between 45% and 60% of the urban labor force.  The proportion is probably even greater in rural communities wheremost people work in subsistence agriculture.

Onyenechere reminds us that just because health services are available, it does not mean that the poorer people in the informal sector can access these. People in the informal sector have their own informal ways of raising money for health care. Yusuf and colleagues found that rotational credit/savings schemes have been used to finance health services, thus increasing access to a social service that many could not easily afford.

med-shop-alagba-2.jpgSo how do people in the informal sector get malaria control services? The local butcher, carpenter or seamstress certainly does not keep a medical clinic on retainer. Most people in both rural and urban settings rely on the patent medicine seller or pharmacy shops.

A healthy and productive workplace is essential for national, community and individual development.  We need to be a bit more creative in ensuring that the informal sector and its employees have the same access to malaria prevention and treatment services as those working in the larger commercial and industrial sectors.

Policy reform and aid must go together

Last month the philanthropic community – government, international, corporate, donor, non-governmental and media partners – met in New York to promote “health among the world’s poorest populations.” Global Health Progress explained that this event was held to “discuss ways to strengthen partnerships toward achieving the Millennium Development Goals (MDGs), especially in areas where progress has been slow and stronger multi-stakeholder participation would be beneficial.”

With the billions of dollars now available annually for health/development aid from multinational, bilateral and philanthropic sources, this group appears to have something to celebrate. But is aid and money the main answer? Paul Collier explains that this is only half of the story:

Poverty in the developing world will decline by about one-half by 2015 if the trends of the 1990s persist. Most of this poverty reduction will occur in Asia, however, while poverty will decline only slightly in Africa. Effective aid could make a contribution to greater poverty reduction in lagging regions. Even more potent would be significant policy reform in these countries. We develop a model of efficient aid in which flows respond to policy improvements that create a better environment for poverty reduction and effective aid. We investigate scenarios of policy reform and efficient aid that point the way to how the world can cut poverty in half in every major region.

In a New York Times review of Paul Collier’s new book, WARS, GUNS, AND VOTES, Kenneth Roth highlights the following:

Collier’s primary conclusion: democracy, in the superficial, election-focused form that tends to prevail in these (pseudo-democracies), “has increased political violence instead of reducing it.” Without rules, traditions, and checks and balances to protect minorities, distribute resources fairly and subject officials to the law, these governments lack the accountability and legitimacy to discourage rebellion. The quest for power becomes a “life-and-death struggle” in which “the contestants are driven to extremes.” Collier’s data show that before an election, warring parties may channel their antagonisms into politics, but that violence tends to flare up once the voting is over. What’s more, when elections are won by threats, bribery, fraud and bloodshed, such so-called democracies tend to promote bad governance, since the policies needed to retain power are quite different from those needed to serve the common good.

The common good of course includes effective and equitable programs against AIDS, malaria, TB and the neglected diseases. In violent environments that often lead to displacement of populations these diseases thrive.

Until the structures of government are geared to the common good and not to helping powerful parties retain power, we may never see the end of malaria and other devastating diseases.  International donors and philanthropists need to ask themselves what they are doing to promote good governance along with their financial aid.

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Readers may have noticed that we have not been using many photos in our recent entries.  We could add previously uploaded photos to new stories, but not upload new photos.  This problem relates to storage space and hopefully will be resolved soon.

Human rights abuses contribute to malaria

Medecins Sans Frontieres neglect-of-water_sm_bbc.jpgrecently listed 10 top crisis areas that highlight in many instances the interrelation between human rights abuses and poor health. Recent news on two of these areas, Zimbabwe and Burma, shows even stronger links to malaria.

ZWNews quotes an IRIN report: “‘There is no food, we have malnutrition, there is cholera, now we are expecting a malaria outbreak,’ said an exasperated Amanda Weisbaum, the emergency manager for Save the Children, UK, in Zimbabwe.” After suffering cholera and malnutrition, “With the onset of rain, there are mounting concerns of a possible malaria outbreak ravaging immune systems weakened by cholera and malnutrition, ‘especially among those aged under five,’ said Weisbaum.”

The government even recognizes the threat of the rainy season. The Herald reports that …

HARARE City Council has embarked on a programme to clear stormwater drains with the assistance of residents under the food-for-work programme at a time the United Nations Children’s Fund has contracted trucks to speed up the removal of refuse in the city as a measure to curb the spread of malaria and cholera.Under the programme, residents in high-density suburbs are paid for clearing the drainage systems in their respective areas.

A BBC reporter notes that, “The country that was once the jewel in Africa’s crown, able to feed itself, heal its sick and educate its people to the highest standards on the continent, is now in a pitiful state.” The BBC has been showing the link between Zimbabwe’s current problems and its human rights violations that contributed to the present economic, political and health crises.

In eastern Burma “Access to maternal health-care is extremely limited and poor nutrition, anemia and malaria are widespread in eastern Burma, which increases the risk of pregnancy complications,” was a finding of researchers from the Johns Hopkins University, as reported in Medical News Today. The full article in PLoS Medicine reported that, “Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites.”

The Burma situation results from “Human rights violations – such as displacement and forced labor – (that) are also widely present, and in some communities forced relocation doubled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.”

A disregard for human rights and a breakdown of health services, especially for the most vulnerable, appear to go hand in hand. Another call for peace in 2009 is urgent.

How Does Freedom of the Press Affect Malaria?

the-press-kisumu-2.JPGThe BBC has reported that, “The Kenya Communications Amendment Bill, which was passed by parliament, gives the state power to raid media houses and control broadcast content,” and at the same time, “Information Minister Samuel Poghisio insists that the government is committed to press freedom.”

Internally, the passage of the bill has resulted in protests and arrests. Initial reports said 23 had been arrested. Later reports in the Nation raised the number to 70. The police were worried that defense of basic freedoms might mar Independence Day celebrations.  The Nation noted that this move marked “45 years of freedom, one giant leap of censorship.”  The oposition Orange Democratic Movement indicated that it would go to court is the President signed the Bill.

It did not take long for the police to take the intent of the new bill seriously. People protesting current economic conditions during the Independence day celebrations were dispersed. Then “Police have turned their heat on journalists after they dispersed protesters at Ufungamano House in Nairobi. On Sunday, they unleashed police dogs and lobbed teargas canisters at the battery of journalists who were recording their showdown with the protesters. Journalists had no option but to film the advancing police officers from the safety of their vehicles.”

Externally AFP reports that, “The United States on Saturday voiced concern over a media bill which was recently adopted by Kenya‘s parliament and curbs freedom of the press. The United States is very concerned about recent actions which potentially threaten freedom of the media in Kenya,” the US embassy said in a statement.” Reporters without Borders has asked the Kenyan President not to sign the bill.

What does all this mean for malaria?  The new bill reflects a government sensitivity to criticism. According to the BBC, “the new bill gives the minister for internal security the power to raid a media house, search its premises, dismantle broadcast equipment and take a station off air.”  What if the press is critical of the way the government handles major donor funding for malaria.  A letter to the Nation looks at the issues at stake.

Politics, bad governance, impunity and the Government’s reluctance to fight corruption are working against Kenyans. Sometime back, the Global Fund slashed its contribution to the fight against HIV/Aids and other parasitic infections in Kenya, citing misappropriation and mismanagement of funds for its action. Kenya has failed for the fourth consecutive year to qualify for the Millennium Challenge Assistance from the US aid development programme. Of the three East African countries only Tanzania made it to the finish line.

Freedom to monitor malaria program performance and undertake advocacy to ensure proper implementation by civil society and the press is essential for accountability and success.

Equity for Minority Groups

The group Drive Against Malaria has focused on “malaria prevention for the Bantu and ignored Pygmy population in this difficult to reach area by distributing LLITNs and ACTs and providing diagnostical support,” in Cameroon.

It is not clear whether the Pygmy areas of Cameroon were intentionally left out of national malaria control plans, but the Global Fund Round 3 Malaria grant for Cameroon specified tha “Premises will be identified in the Far North, North, West, South West, North West, Adamaoua and Centre provinces, and provided with net treatment equipment and skilled staff to ensure training and quality control of the community treatment units.” Not mentioned were Littoral, South and East Provinces where pygmy populations are more common.

Even if there was no intentional neglect of this minority population, the reality of grant implementation shows that ITN coverage is far behind expectations. Even though retreatment centers have been set up in 6 provinces and around 900 communities, only 65% of the targeted children has been reached and 45% of the current target nets has actually been retreated three years after the grant started.The Global Fund concludes –

At the end of the third year of implementation of program activities, performance remains somehow not fully satisfactory. Delays in procurement of bednets have impacted the achievement of related targets, while the reporting of pregnant women receiving IPT is not fully convincing as data is based on estimation.

The figure below is extracted from the GFATM progress reports.
cameroon-gf-malaria-grants.jpg

The Round 5 Malaria Grant is approaching the end of Phase 1. Efforts to ensure access to ACTs is proving challenging. In the most recent progress report one can see that  only 17% of targeted health facilities reported no stock outs lasting > 1 week of malaria drugs. Likewise only 62% of targeted health facilities had ACTs. Also only 43% of children under five in targeted areas received correct malaria treatment.

The Global Fund had this to say about the Round 5 grant performance: “Six months after program started, results are disappointing with only very few activities having been implemented.”  Clearly when grants don’t perform, minorities have a lesser chance of being served, assuming their regions, districts and communities are even targeted.  Greater accountability is needed.