S P ERSPECTIVE Best Buys for Global Health

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