STOP THE RAIDS AND DEPORTATIONS!!!

Today is the National May 1st Movement for Worker and Immigrant Rights. Visit the Mayday Movement Blogspot to find out more about events going on around California, Arizona, Nevada, Tijuana among other places.

The movement calls for a "Great American Boycott": NO economic activity, NO shopping, NO work and NO school for immigrants and their children, to show "what a day without immigrants in the economy signifies."

This can be considered a fight for human rights, but it is also more personal than that. It's a fight to keep families together. Children born in the U.S. are marching for the security of having their parents by their side. Immigrant parents are fighting for the right to raise their kids in peace in a country with which they've built a mutually beneficial relationship. Below is a photo from today's New York Times article of a father and a son whose mother was deported to Honduras two weeks ago in the early hours of the morning.


It's not easy to know exactly what to do, but what not to do--such as sudden deportation and raids--should be easy for public officials to figure out by now. For my thoughts on 21st century global immigration and to read other papers discussing various global health issues, check out our collection of essays on Emerging Trends in Global Health.

Mobilizing communities: How far would you go?

First, check out this video about Treatment Action Campaign (TAC), South Africa's HIV movement led by HIV-positive citizens to demand ARV's and accountability from their government and transnational pharmaceutical companies.

It is so moving to see these people fighting for their rights. It reminds me of the quote by Margaret Mead that was brought to our attention by Dr. Shahi in class last week:

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it's the only thing that ever has.

I believe that mobilizing communities is going to make the biggest difference in our reaching the Millenium Development goals. After all, excluding select groups from centralized processes is the very reason there is so much "unfinished business" in human development. Then we went and made it worse by telling them exactly what they need to do to make it better. Now, we seem to have finally come to the realization that involving (and hopefully, empowering) disenfranchised communities is the only way to truly make a difference.



The above picture, from the TAC website, is another dramatic example of community mobilization efforts. We can get lost discussing the merits of PPPs, cost-benefit analyses, global data systems and stakeholder summits. There are other ways to get things done.

What lessons can future health professionals take from this? It goes back to the title of this post: How far would you go? How far would we be willing to go to fight for ARVs, for polio eradication, for universal health care? Would we be willing to dance on a stage to rile people up against the injustice of a black infant mortality twice as high as that of whites? Would that be too unprofessional, too personal, too close to home?

After watching the TAC video, I really don't think so.

Ethics & Global Public Health

M.Lakshman, AP Photo / healthystartokawalton.org


Last week we discussed the role of ethics in emerging trends in global public health. Dr. Shahi asked an important question: Are we really confronting a new era in ethics, or are the challenges we face today the same as those faced by previous generations?

Like most of the class, I agree that the questions we must ask ourselves now, with regard to ethics, are more important than ever before. The impact of technology on our lives is immeasurable, and it's advancing and impacting society on a greater scale than we can quantify. In the face of persistent disparities (rich/poor, north/south, white/ethnic, urban/rural, male/female), there could be a scramble to end the shame that accompanies the fact that the two children pictured above exist in the same era, in the same global community.

To be fair, scientific and technological developments are not always a scramble, nor do they necessarily present ethical dilemmas. But products like ready-to-use therapeutic foods (RUTFs), labs-on-a-chip (LOCs), GM foods (such as Golden Rice), bioremediation techniques and many other recent and imminent advancements do pose ethical questions, particularly when thinking about long-term development. For instance, as my colleague Liyan Moghadam mentioned several weeks ago, one of the pitfalls of RUTFs is the fact that it is designed to nourish those in immediate danger of starving to death. What do we do after the peanut butter? Pat ourselves on the back??? And what about GM foods? Some independent studies have found links between GM potatoes cancer in lab rats. Do we really know what its impact will be on the beneficiaries/victims of (fortified) GM foods?

But we also have to ask ourselves: is this all rich man's talk? Even in our own community, there are populations that can't really afford to talk about ethics the way we do. Living a moral, honest, insulated life is much easier when all your primal needs are met (and then some). Does this mean we should consider different ethical standards for different populations? RUTF factories in Uganda bring jobs to people desperately in need of livelihoods. Inexpensive LOCs give the power of knowledge to people suffering from treatable illnesses they didn't even know existed (but will they get those inexpensive drugs that cure them? the food? the clean water?).

If you ask the people who would benefit, I don't think they would ever say no to a new technology that gives them more tools for life. But I think the developers of these exciting tools (who obviously have some knowledge of their importance to society) have a responsibility to think of not only the benefits but some of the challenges that their innovations present. They should work with organizations like the Institute for Global Ethics to ensure that those worldwide north/south, white/ethnic, urban/rural, educated/uneducated disparities we're seeing are not exacerbated--and are perhaps even diminished--by new technologies.

Because with regard to equality, our track record with science and tech so far raises some serious red flags (eg, read this poem on the global digital divide).

Public-Private Partnerships for Global Poverty Alleviation

In a previous post I explored the possibilities of public-public partnerships (PUPs) in establishing vital infrastructure (e.g., water, electricity, city planning) to combat poverty.

This entry is all about public-private partnerships (PPPs), and the case for their potential to alleviate global poverty is unequivocal. PUPs simply cannot compete with the powerful combination of yin and yang that results from public-private collaboration.

First off, for a great list of various PPP models and a diagram of where each lies on the spectrum of public/private risk involvement, see the Canadian Council for PPPs website.

We all know what the public and private sectors stand for. The public sector is concerned with meeting basic needs and ensuring social justice. The private sector is innovative and profit-driven. Inherent in both sectors are problems that endanger human welfare. What happens when you put the two together? With the right leadership, you could have an integrated mechanism for sustained human development.

A little background: in the late 1990s, the IMF and the World Bank implemented the now heavily criticized Structural Adjustment Programs (SAPs) in developing countries to manage debt and reduce poverty. The SAPs emphasized trade liberalization, which, in the way it was implemented, might be described as mutton dressed as lamb...developed nations open up their markets for trade with less developed countries (LDCs), and then heavily subsidize exports so that LDCs with newly open market policies cannot compete. SAPs have been replaced by another acronym, PRSPs (Poverty Reduction Strategy Papers), which are required by the IMF for a country to qualify for aid.

Ugandan President Musevani put it poignantly when he said, "We are asking for the opportunity to compete, to sell our goods in western markets. In short, we want to trade our way out of poverty."

Trade liberalization can do that, but most LDCs are not at the point yet where they can compete with developed nations' subsidies. PPPs could be useful here. What is needed is federal government stewardship over "free" trade. LDC governments must seize back ownership of their economies, develop criteria for collaborating with international partners in the private sector, pick those partners wisely, and ease into financial mechanisms that work toward Musevani's plea.

"Our job is not to give people fish. It's not to teach them how to fish. It's to build a new and better fishing industry."
-Bill Drayton of Ashoka Alliance

On a side note: Where do you and I come in? We can be social entrepreneurs, who seem to be able to harness the yin and yang and everything in between. See these videos of successful innovators for inspiration:

Ashoka Alliance founder Bill Drayton
Grameen Bank founder Muhammad Yunus

On the Future of U.S. Health Care Financing

No matter how much we talk about global health issues like infectious disease, maternal health, and the role of education, at the heart of every problem we are facing is the question of financing health care initiatives. Perhaps the only other variable so crucial to population health is stewardship, and a large part of stewardship concerns judicious management of funding.

Two videos recommended for this week brought up provocative issues on the future of health care financing in the U.S.: Uwe Reinhardt's lecture and the California OneCare initiative. California OneCare lobbies for universal health insurance, calling for swift steps instead of small changes. The biggest issues we face are administrative costs and lack of access to care for a staggering chunk of the population. Also disturbing are inequities in the quality of care people receive, a measure closely linked to SES and race.

Many other countries use a single-payer system to control administrative costs. Canada and the UK are just two examples. Health care investigators in these countries would be quick to tell us that the single-payer system is no panacea...it has its own disadvantages, like everything else. However, at the heart of the current health care crisis is a civil rights issue that the single-payer system might address: unquestionable inequity in the ability to attain something that is, at least ideologically, universally considered to be a basic human right.

Even developing countries understand (and act on the understanding) that the way we do health care doesn't cover the most vulnerable people. In this country, over half of family bankruptcies filed are a direct result of medical expenses. 3/4 of these people have jobs. They are productive individuals of society crippled by a health care system that's supposed to increase their productivity. Instead, it's leeching it.

If that's not convincing enough, consider this: a 1% decline in income in the U.S. translates into an increase in mortality rate of 22 deaths per 1000. In Canada, no association is found between income inequality and mortality rates. Infant mortality rates show similar results, with the world superpower ranking in the 40's on the list of country-specific rates.

Fundamentally, health is more important than money. Anyone who's ever experienced a serious illness, even a bout of flu, can tell you that without your health, your money doesn't mean much.

Unfortunately, that piece of wisdom is no longer true, and it's least true in places like the U.S., where both health and money are available, but money is infinitely more important than health. Here, money buys health and happiness. What is wrong with this picture???

Back to that paradigm shift we talked about. Sure, we'll have to iron out some kinks in a single payer system to adapt to our needs as a country. But what we're doing right now--taking those kinks and calling them reasons not to act in the best interests of human beings--can't continue. We must first accept that inequality of some sort may always exist, and then go about decreasing it as surely as we can, as other nations--even less developed ones like Korea, Brazil, and India--have done.

And one more thing: an equality of opportunity, as the U.S. has historically been praised for having, is not the same thing as equality. There are several forces, some known and others unknown, working against equality. For instance, racism and SES interact additively to produce poorer health outcomes for certain groups of people. This holds true even when patient characteristics are held constant. What does this mean? It means that somewhere among health care providers and institutions, inequality is being perpetuated. It means that addressing individuals is not enough; the entire establishment must be examined. We must ask important questions: Are doctors giving every patient the same quality of care? Are there good hospitals in largely ethnic areas? Good schools? What are the differences? Our country likes to believe that racial segregation was so long ago that its effects are no longer profound. We have made great strides (remember, in the late 18th century an African-American slave was only roughly 3/5 of a human being). But vigorously addressing contemporary manifestations of these issues will greatly aid a successful reworking of health care financing in this country.

In order to treat some persons equally, we must treat them differently.
-Harry Blackmun

Internet Access and Health Outcomes

my Grandma:
one of the smartest people I know!

I recently went back to my hometown for a visit and realized that some of my dearest friends and family do not have access to the internet. This may seem obvious and acceptable, but to me it is neither.

Who are these people in my life who are so archaic they don't have internet access even though they can afford it? Well, 1) my grandma and 2) dear family friends who are not-so-recent migrants.

I was studying at my aunt's house the other day when I decided to see what my grandmother thinks of YouTube.com. (This post is supposed to be about health outcomes...we'll get there). I typed in 'Andhra Pradesh' (our home state in India) into the search bar, and six pages worth of videos came up. We watched a few videos on Indian freedom fighters during the time of Gandhi. My grandma was a little girl during India's freedom fight--she recalls witnessing her elder brother being beaten by British-hired Indian law enforcement officers for his revolutionary activities. The videos, which were even narrated in her native Telugu, brought back all sorts of memories for her. She even talked about writing a book about her brother's role in the fight for Indian independence. She was jazzed.

My aforementioned migrant friends could benefit from internet access too. Some of them don't speak English at all. They make enough money to afford a computer and the internet, so the barriers are not financial. They just don't have the freedom to do things like take time off from work to do something frivolous like educate themselves. But there is a crucial point to make here--just as we discussed in the first weeks of class, and just as UK & Netherlands authors Wagstaff and Van Doorslaer (gold standard researchers on poverty and health) point out, the effects (i.e. the cost) of not having things like the internet are much more significant for disadvantaged people. In other words, it would mean a great deal more to my grandma, or to my migrant friends, to have internet access, than it means for someone like me to have it.

What would it mean? The possibilities are endless. For my grandma, maybe it means delayed onset of dementia. Less depression, anxiety and social isolation (she can connect with others and entertain herself as she gets older and cannot move around as much). Fewer medical episodes. For migrants, it also means access to empowering information that may well give them the freedom to see education as a basic right/need rather than a peripheral idea. It would mean access to services that they would otherwise have no way of knowing exist. Faced with all this new technology, it seems that education is more important than ever. Increasing access and utilization are key.

I spent some time teaching my grandma how to use my aunt's PC. She's a quick and eager learner in her mid-80's. Her biggest challenges were learning how to operate the mouse and focusing her eyes on the screen. I wonder why the local senior citizen center offers arts and crafts, but not computer classes? There's so much human potential out there, sometimes in the most surprising places. From that perspective, the field of public health would do something incredible if it focused on ways to give people the tools they need to live productive lives. Because for many (if not most) people, feeling productive = feeling truly happy.

Biotech for Development: A promising solution or a pipe dream?

There is no easy answer to the debates over where pro-poor development funds should go. As part of the whole paradigm shift we keep referring to, I think every field has to redefine its priorities. Biotech was the topic last week, and one of the controversies surrounding pro-poor biotechnology is the question of whether the vast amount of funding required to develop a new diagnostic, a new vaccine or a new drug is really worth it. Rich countries can argue that drugs already developed are very poorly distributed. Why fuel new innovations that will only widen the gap?

While committees concern themselves with that, paradigm shifters in the field have showed some promising advances, including new vaccines and low-cost treatments that are showing promise in advanced-level trials (anti-malaria vaccine, paromomycin treatment for kala azar). In a
New York Times article posted by Dr. Shahi awhile ago, Tina Rosenberg points out that vaccines have only been around for 20 years. In 20 years, they've made an enormous difference in a child's ability to survive the first five years of life! Who would have thought that such a labor-intensive project, which requires hunting people down in all corners of the world one by one, could be so successful? Who could have predicted that wars would be halted for vaccination campaigns? And yet it happened, and it changed everything.

Another example: The human genome was discovered two years ahead of time, and well under budget. According to one account I recently read, these unexpected outcomes were largely attributed to competitive cooperation among investigators. Again, it would seem impossible to unravel something as complicated as the human genome ahead of schedule simply because someone wanted to beat everyone else to it. And to do it more cheaply than expected, to boot. But that also happened, and it changed everything.

But we seem to forget history. Or maybe we're unaware that we're the ones making it. It's ironic, but one of crucial ways of achieving a paradigm shift is, I think, examining history in an attempt to understand just how we got to where we are now. There's an astonishingly accurate (and somewhat grim) picture of human nature buried in there, and confronting it proactively may provide some rationale, motivation, and clues to shifting that paradigm.

To learn more about biotech's role in global health, check out this article on the ten most promising biotechnologies for human development.