Power to the People

Why do aid agencies assume they have to do it all? As we know from our readings on global health initiatives, local people and frontline providers of goods and services must be empowered to distribute any kind of development aid that gets dished out. It's the only way for that development to have any kind of lasting effect.

While researching for my paper I realized just how great a tool information technology would be for developing countries. Information is power. That Chinese baby I mentioned in my last blog? If her parents had the internet, they could have diagnosed her malnutrition themselves, before it was too late. And they would have, except for the fact that people like them, who have access to limited information and sub-par goods and services, don't even know that the internet exists. Many of these poorest of the poor don't even know that they are referred to, by some, as human rights violations.

The internet would be a wonderful tool for people in rural, developing areas to have. It would allow them to communicate suspected infectious disease outbreaks, request needed supplies to uphold quality of care, and put the power of information in the hands of those who have the greatest incentive to use it wisely and well. Access to information in areas where governing bodies are highly corrupted would also force centralized powers to be more transparent, more accountable, and more in-tune with the wants and needs of the people they're supposed to be serving.

At What Cost?

One of the assigned articles in our class on public health challenges in China recounts the story of Rongrong, a newborn baby whose parents were among villagers sold fake milk powder to feed their infants in 2004. At least 200 infants were severely malnourished as a result of consuming this cheap powder, and village doctors, who aren't rigorously trained or regulated, failed to recognize the signs of malnutrition. Instead, they called it the "big head disease"--a classic indication of malnutrition. Rongrong died in a city hospital. Her parents are responsible not only for the cost of her care prior to her death, but also for the illnesses her mother now suffers.

According to China Daily, rural people are most susceptible to counterfeit food products, where there is very little regulation. Companies wanting to turn a profit have apparently found their target population in China's most precarious citizens. Not only that, what kind of physicians fail to diagnose severe malnutrition?

The original article, published in The Economist, can be found here.

Learn more about the unexpected, adverse outcomes of globalization on the "have-nots": The UN Development Project's report on "Inequality & Development"

Making the case for capitalism: John Norberg video

Compounding the issue: Another video on politics, wealth, and health

An Anthropologic Approach

I really enjoyed the anthropologic approach to epidemiological transitions in the article assigned last week. The authors seemed to have done a comprehensive review of the current theoretical construct and then re-framed it entirely, just as Dr. Shahi is urging us to do for our topical review papers. The recurring patterns in human history are undeniable and informative--just as hunters and gatherers began to see a spike in infectious disease upon settling into communities, we will likely see new diseases emerge as the rising global population is forced into previously uninhabited areas. The article mentions a history of species jumps from other organisms to humans--as we all know, we're facing this possibility now with H5N1. Migration also has a history of importing disease from one population to another; Columbus may have brought back syphilis from the New World in 1493, and 5 centuries later, a significant percentage of MDR-TB cases are found among immigrants.

It's true that mother nature creates amazing bugs with very interesting properties. Yet, it's also true that we humans have a profound effect on mother nature--our behavior is altering entire ecosystems, which is shocking (e.g., the proliferation of vibrio cholerae due to increased algae blooms from global warming). Better than destroying the entire mosquito population, or pushing for new, stronger, better antibiotics, perhaps we should (also) look for solutions that will last. Whether human behavior changes or not, new bugs will emerge. But changing how we use antibiotics, how we treat the environment, how we live in communities and how we interact globally may determine how well those bugs thrive on us.

Empathetic Solutions

I was reflecting on Dr. Shahi's urging us to approach global health with empathy, and one of the things that I didn't mention in my first post on the Mondana community in the rainforest is the roadblocks that FUNEDESIN, the founding organization, had to overcome to get children to come to the school. Parents are reluctant to send their children to school, not because they are against education, but for various reasons. Some families live deep inside the forest ("bien adentro") and it would take a good two hours to get to the school. Other families have so many children that they need the older ones to help care for the younger ones. They rely on their older children for help, and can't afford to lose that pair of hands for 8 hours each day. Still others have no way to pay for an education.

FUNEDESIN designed a successful school with full enrollment (and a waiting list to boot) by taking all these factors into consideration. Families don't pay tuition. Instead, they pay with corn, which the teachers actually eat. They are also given nutritious meals (there are much fewer fish in the Napo river due to oil company activity...plantains comprise a large portion of the diet). The school is set up as a boarding school; perhaps surprisingly, parents found this set-up more agreeable than day school. A group of 32 students comes to board at the Yachana School, and stays for two weeks at a time. Then those students go back to their homes to contribute to family life for the next two weeks, and the second group of 32 comes to school. The two groups rotate in two-week blocks.

Yachana students also get free medical care at the Mondana clinic. Their families are often seen waiting in line to get medical care, too. As I mentioned in my earlier post, the students are now eligible for grants to continue their studies in Quito. This opportunity means that a child from a rainforest community and a child born in the capital city might attain the same level of education (although of course there's a long way to go until that's really true).

One of the students I met there had traveled from a small, nearby city to attend Yachana. I wondered why his whole family would come all the way to this little community just for Yachana, when his hometown was more urban and thus probably had more opportunities. But I think that might be an indication that Yachana is providing for its students and its community something that is hard to find in human development efforts: an empathetic solution.

To learn about another empathetic solution for rural development in Bangladesh, watch this video on the Bangladesh Rural Advancement Committee (BRAC).

Learning From History

In the article"Globalization and Health Viewed From 3 Parts of the World," the author states that international institutions (e.g., UN, WHO, IMF) must re-examine their partnerships to eliminate private interests and to protect international equality.

Is this even possible? If so, how do we achieve it?

The idea of a global health bureau is not new. In fact, the first recorded series of global health meetings was held in 1851 (those of us in PM 566, the China class, are familiar with this). These "International Sanitary Conferences" provided a platform to discuss best practices to control the spread of disease during trade activities. It sounds like a noble goal, but in fact the motivation for seeking global participation was that in an emerging era of international trade, such collaboration was necessary to protect local health interests. 19th century colonialism and imperialism also provided considerable incentive to create global health solutions--Africa, Asia and the Caribbean were seen as exciting European discoveries. So while the Sanitary Conferences symbolized global cooperation, they were at least partially driven by ulterior motives and hegemonic relationships. Sound familiar?

Information is one of the greatest tools for development we have these days, and in terms of global cooperation, transparency is key. Whether the goal is controlling infectious disease, maximizing economic growth, or protecting global security, it is now imperative that information is shared on a global scale. This has not been done, and its effects are perilous (SARS in China, US foreign policy, former Soviet Union's Biopreparat, etc.) and long-lasting. However, enough nations have now united in pursuit of the MDG's to make transparency and accountability in foreign policy matters a logical and necessary next step. Until we, as nations and as international organizations, take that step, personal interest will cloud the proper flow and use of capital toward achieving the MDG's and any significant human development.

Just for reference, the article we were assigned to read in PM 566 is entitled, "International Efforts to Control Infections Diseases, 1851 to the Present" (JAMA, 2004).

The Future is Old

As developing countries catch up to the Western world in everything from technology to McDonald's to depression, I think one of the most interesting public health issues to discuss is that of the mounting aging population. According to the article posted under week 1, "Global Aging: The Challenge of Success", by 2050, approximately 80% of the expected population aged 65+ (1.2 of 1.5 billion) will reside in today's less developed regions. As global public health professionals, we must keep this in mind when allocating funds and implementing policies. As social entrepreneurs, we might also recognize an opportunity to create innovative solutions to the anticipated costs of the disease burden of the elderly in developing countries.

In the US, UK, and other European nations, the elderly population is indeed expected to grow, but the bulk of the growth is set to happen in countries like India and China. Other countries with large populations of old people (aged 65+) include the US, Japan, Germany and Russia. Ironically, Russia and Japan are also on the list of countries projected to experience the worst decline in total population—12 and 11 million, respectively. So it is the age structure of the population that is changing. This means that the number of productive people (defined as aged 20-64) in these countries is predicted to drop at an alarming rate, seriously affecting the GDP and creating new health challenges.

In places like India, China, Thailand, Colombia and sub-Saharan Africa, a different phenomenon is developing. With increased buying power, better education and more sophisticated technologies than ever before, these nations are experiencing a similar increase in longevity and a surge in the aging population. According to the article, for instance, Malaysia and Colombia are expected to triple their older populations between 2000 and 2030; sub-Saharan Africa should see an increase of nearly 50% between 2000 and 2015. However, these countries are not experiencing as sharp a decline in their working-age population; while many are seeing ever-decreasing fertility rates, the decrease is not yet reflected in the age structure of these populations to the extent that is seen in more developed countries.

The implications? Developing countries will have more human resources—defined here as sheer numbers of working-age people—than developed countries. Yet simultaneously, the disease burden of the elderly, who in any country consume a disproportionate amount of health resources, will be more of an issue in these less developed nations than in places like the US and Europe. As their economies flourish, and their middle classes expand, will they focus on health care for the elderly? Or will they prioritize instead the health of children and workers, who are the promise, the bread and butter of the nation?

If developing nations do not implement health care policies that care for the elderly, entire countries will suffer from the oversight. India is an example of a country that recognizes this, and responded in 1995 with the centrally funded National Old Age Pension Scheme. While this scheme is 100% government-subsidized, it must be noted that each country is different in terms of its culture, beliefs, resources, history, diversity, form of government and much more. What works in India will not work in nearby Malaysia. What works in an Arab country might be totally inefficient in South America. However, as the article stated, we as future professionals should be thinking in terms of 4 pillars of financial support for health care: public pension, occupational pension, personal savings, and “gradual retirement” of the elderly. Playing with these four forms of funding to find the right formula is and will be an exciting challenge in raising developing economies out of poverty so they can pursue health at each stage of life.

For more information, read "Global Aging: The Challenge of Success."

Thinking Past the MDG's

With the impressive scope of the UN's Millenium Development Goals, it may seem premature to be thinking beyond these eight milestones of global improvement. But to make good on those goals, and to achieve the world vision they represent, that is precisely what needs to be done.

So what do we do after we reach the MDG's? It's 2015. 50% less people (than in 1990) live in hunger and survive on less than $1 a day. There's universal primary education available to every boy and girl in the world. Women are more empowered, mothers and babies are dying less frequently, HIV/malaria/TB infection rates are declining, governments are implementing environmentally sound policies, and the internet is now available to 30% of the world's population (up from 14%).

Have we achieved health for all?

Not yet. Because even if the above is accomplished by 2015--and the verdict is still out on whether it will be--what will those kids do with their primary education? How will women use their newly empowered social status to grow and improve? Will family planning be implemented in time to stave off the surge in population that may result from successfully battling HIV in countries like Africa and India? How will countries steeped in political/social/ethnic conflict be encouraged to collaborate for the wellbeing of their citizens? How will developed countries collaborate with developing countries? These may or may not be poignant issues in 2015, but exploring the path ahead is always useful.

Now, and in 2015, empowered women benefit from group micro-loans, whereby $300 can be invested in a community-based business that manufactures, say, peanut butter. These vendors must be given the freedom to sell their product wherever the demand is. Developing as well as developed countries must recognize the importance of free market economies and lift trade barriers--there are enough money and resources out there for anyone smart enough to figure out how to capture them. Once the MDG's are attained, and the globe is a little more flat (to borrow from Thomas Friedman), it will become increasingly true that this approach can benefit any individual or any country that adopts it.

Technical schools may be another area of focus in another ten years, when the poorest children of the world will (hopefully) be able to take primary education for granted. Literacy, math and geography are useful building blocks, but they are just that--stepping stones to learn professional or technical skills. Developing countries must have quality institutes of higher learning so that it makes sense for the new generation to continue their education in their own nations, and use their skills to build up their own people.

As people start dying less and living longer, efforts must also be made to eliminate urban sprawl and increase city planning. With the advent of the third epidemiological transition, wherein the human race is being revisited by old and new bugs, the disease burden may be doubled. One foreseeable way to limit the spread of infectious disease (apart from better sanitation, part of MDG #7) is through city planning and balancing the urban/suburban population proportions, particularly in places like China, India and Africa. MDG #7 cites improving the lives of at least 100 million slum-dwellers as an objective, yet it doesn't offer any strategies for doing it.

And what about global cooperation? That is, after all, one of the most crucial factors in closing the gap between rich and poor. Debt forgiveness, aid, new loans, incentives for innovation...the degree and quality of international participation will determine how far we can go in making health a resource that is truly available to every human being. Interestingly, it will also determine how important a player each developed nation will be in the world's future.

Sustainable Development

Our intro class on emerging trends in global health reminded me of an interesting model for sustainable development I saw in the Ecuadorian rainforest in 2006. While I went there to learn about the practice of rural medicine, I was exposed to a promising business model that exploited the tourist industry to bring healthcare, education and buying power to a small region along the Napo River called Mondana.

Like Dr. Shahi said, 90% of healthcare is not accomplished by physicians. What was impressive about Mondana's set-up was not the high level of medical care available to the community. In fact, the clinic lacks any special equipment and must often refer patients to the nearest city, Tena. Many patients are unable to afford the cost of transportation (about $7 U.S.). What was impressive is the establishment of a boarding school that teaches rural children basic education as well as skills in making jewelry, giving tours of the rainforest, and running a hotel. These children get hands-on experience working at the Yachana Lodge as housekeepers, tour guides and boatmen. Proceeds of Yachana go to fund the school and keep the clinic running. The school is now an accredited establishment, and children are receiving grants to study in the capital city of Quito. A few of these kids will go on to acquire professional skills which they can use to improve the status of Mondana and nearby communities.

Along with Yachana, a gourmet chocolate company was established to supplement the lodge's income. Using slow-roasted cacao beans and other ingredients found in the rainforest, locals have created a unique chocolate product that I was very surprised to find in drugstores in Quito, and in fine health food stores here in the U.S. Like Yachana Lodge, the chocolate caters to the palate of developed countries, and that's how a rural rainforest community has (hopefully) begun its way up the ladder of sustainable development.