Change.org's Global Health Blog

For Sale: Lethal Malaria Drugs

Te-Ping Chen — 2010-02-09T09:49:00-08:00

Imagine that you head up a nonprofit working in Madagascar, Senegal or Uganda. You've got a great mission statement, an enthusiastic set of donors, and you're making great strides in fighting malaria on the ground. In your last year, you managed to raise a ton of money and have treated 1,000 patients.

Except that, unwittingly, you gave them drugs that don't actually work.

It sounds nightmarish, but that's the situation that plenty of doctors and aid workers easily find themselves in. Poor-quality and counterfeit drugs -- most originating in China or India -- are rife within markets across Africa. In fact, a new study backed by USAID and the World Health Organization found that 26 to 44% of artemisinin-based malaria drugs sold in Madagascar, Senegal and Uganda failed quality testing outright.

And we're not talking about sugar pills masquerading as the real thing, either. In some ways, that actually might be less damaging. No, these pills have some curative properties -- just not consistent or particularly powerful ones -- and are riddled with impurities, too. And with patients getting spotty dosage levels, the spread of such pills may actually be fueling a virulent, drug-resistant strain of malaria, Plasmodium falciparum.

It's hard to know where to start in combating this kind of scourge. I've reported in the past, for example, about how even the European Union and the U.S. haven't been able to stop an influx of counterfeit cigarettes from getting into consumers' hands. Porous borders and dismal coordination between national law enforcement play into the hands of flexible crime networks around the globe. (The USAID/WHO-backed study reports that even government-supported programs -- some of which buy medicine with donor funds -- haven't been able to keep bad medicine off the shelves, either.)

For now, getting the best information can help, so that authorities can better pinpoint which brands and locales are particularly vulnerable. It's only the start of the resources that need deployment, though. To give a sense of the urgency behind the issue, some estimates of the number of people killed per year by fake tuberculosis and malaria drugs range up to 700,000 -- the equivalent of four jumbo jets crashing every day.

If that were the headline, we'd see a lot more conversation. As it stands, though, I'm glad to see USAID and the WHO devoting their resources to the issue. It's a start.

Photo Credit: Pink Sherbet Photography

When 'Charity' in Haiti Kills Children

Te-Ping Chen — 2010-02-09T06:05:00-08:00

It's gotten even worse. Okay, we knew that the case of the misguided 10 Baptist missionaries was a sideshow with the maddening ability to vacuum up an excessive number of media hits. But now, it turns out, the case has become something of a main event in its own right -- in fact, it's literally killing children.

That's right. Since the missionaries were arrested last month, the misbegotten travails of ringleader Laura Silsby & co. have had a chilling effect on doctors, aid workers and government officials (you know, the people who have a legitimate mission in helping Haiti with the recovery process) trying to save the lives of critically injured Haitian kids.

Now, the New York Times is reporting that 10 children have died or become worse while waiting for authorization from newly skittish authorities to get on flights out of the country for treatment.

Prior to the Americans' arrest, every day, an average of 15 injured Haitian children were getting airlifted out of Haiti onto U.S.-bound flights. Since Silsby & co. bobbed onto the scene, though, only three children have been evacuated for treatment in the U.S. on private flights. Something about the sight of Americans getting tossed into jail for taking kids out of the country without the proper paperwork has effectively discouraged others from putting kids aboard planes.

"Everything has slowed down, and most pilots are backing out of these medical missions with kids," says Scott Dorfman, an Atlanta pilot. Dorman has hopes of piloting a critically injured Haitian baby to a U.S. hospital this week. Still, though, he says he won't take off until he's obtained the proper paperwork -- which, in a post-disaster zone, is a pretty daunting hurdle to meet.

Then there's the case of the badly maimed, three-month-old Landina Seignon, who the British surgeon tending her says could die in under a week unless she's airlifted out for care. Haitian authorities, though, have so far denied permission for Landina to leave the country, as her parents have not been located.

Plenty has been written about how the missionaries' work in Haiti was no act of charity, and these latest developments make that case far more indicting. No, indeed. However intentioned, their effect has been much, much more sinister than that.

Photo Credit: US_Air_Force

Behind Haiti's Orphan Crisis, Government Neglect

Te-Ping Chen — 2010-02-08T11:24:00-08:00

Thanks to the much-ballyhooed case of missionaries who went kid-snatching in Haiti, the plight of Haiti's orphans has gotten a lot more press in recent days. Not very discriminate coverage, though -- more of the shallow, headline-grabby variety. Which is why it's so refreshing to see the Stars and Stripes taking a deeper dive for readers in their latest story.

Prior to the earthquake, Save the Children estimated there were 380,000 Haitian children living in orphanages. And since the earthquake, the number of children who've lost their parents has more than doubled.

Long before the Jan. 12 earthquake, children in Haiti were often commodified by their poverty -- trafficked for labor, sold on the black market to adoptive parents, or driven into servitude. And, as the S&S writes, long before the latest gaggle of Baptists trooped into Haiti to stir up some headlines, there was an extensive history of missionaries behaving badly, as well.

There's the case of the pastor who in 2008 trolled Haiti for kids, telling their parents they would gain a better life at a U.S.-funded orphanage. (Within three months, out of the 28 children sent with the pastor, one child had died, and two dozen more were ill and emaciated.) Or the case of Douglas Perlitz, a Colorado missionary indicted by U.S. prosecutors this September on charges of extracting sexual favors from the teens he housed at an orphanage in northern Haiti. The list goes on.

The bigger issue, though, has been the Haitian government's near-total reticence on the issue. By its own account, the government inspects only half the number of documented orphanages in the country (and plenty of undocumented orphanages abound, too). In 2008, Amnesty International found that far from protecting children, the Brigade for the Protection of Minors, founded by the police to combat trafficking in 2002, had fewer than 20 officers and -- in an eloquent metaphor for how protection efforts have stalled -- lacked even a car.

What's more, according to the State Department's 2009 Trafficking in Persons report, Haiti has no law against human trafficking.

So far on the case of the 10 detained U.S. missionaries, the State Department has stayed publicly reserved, refusing to ask that the case to be transferred to U.S. court. Whether the U.S. should be reaching inside the Haitian justice system to scoop out 10 Americans is another debate -- but for now, the higher priority should be partnering with Haitian authorities to overhaul the lapses their case has helped bring to light.

Photo Credit: U.S. Coast Guard

In Haiti, Aiding the Aid Workers

Te-Ping Chen — 2010-02-08T09:36:00-08:00

For a small nonprofit seeking to assist disaster recovery efforts in Haiti, where do you start? With 200,000 tents needed, rampant sanitation issues and 460,000 people living in makeshift camps, the prospect of setting a spade down anywhere can seem overwhelming.

That's why the nonprofit HELP seeks to target its efforts on one group that's frequently mentioned in the news, but whose needs are less-talked about: aid workers. As director Randy Roberson tells Change.org, "In disasters, the immediate victims aren't the only ones. By helping relief teams sustain their efforts for greater periods of time, we can support efforts to provide more aid to everyone."

After working on the ground in Haiti for two weeks, Roberson says he's seen workers easily fall prey to their environment. Members of the Mexican relief team who had to be aerovaced back home, for example -- victims, he says, of the trauma that they'd experienced after spending days digging bodies out of the rubble. He also describes relief teams whose efforts are jeopardized by lack of food and resources, as well as extreme dehydration. "Conditions are terribly harsh -- it's very hot and humid, and some teams aren't used to that. There's the challenge of contaminated water, which makes dehydration worse. And because people are working in large amounts of wreckage, without antibiotics, even a relatively small wound can become life-threatening pretty quickly."

To support these workers, HELP has been working to provide tetanus shots to aid workers, as well as supplies and the ability to easily make calls home through solar-powered communication equipment. They've also been working to provide counseling to try and stem the onset of post-traumatic stress disorder, which Roberson calls "one of the single greatest needs in disasters that overall goes unaided."

"In relief circles, it's so easy to say we need to be tough, and hunker down and bear it," he says. "But it's important that people talk about what they're going through, and not just internalize it."

Having worked in disaster zones for the past 12 years, Roberson says he's responded to earthquakes of greater magnitude than that which hit Haiti, including an 8.0 earthquake in Turkey in 1999. He's also worked in post-earthquake zones in Armenia, Colombia and El Salvador, but says that the crisis in Haiti has "really redefined the term ‘disaster'" for him. The fallout of the earthquake, he reports, is worse than anything he's ever seen.

Still, though, even as relief efforts rightfully focus on shelter, water and treatment for earthquake survivors, Roberson says he wants to be sure that the international community doesn't forget the needs of the aid workers -- psychological and otherwise -- who make those efforts possible, too.

Photo Credit: zoriah

Why Less Funding for HIV/AIDS Isn't as Bad as It Seems

Andrew Green — 2010-02-06T12:42:00-08:00

When the White House announced its 2011 budget this past week, the response among the HIV/AIDS community to the 9% increase in global health funding was, you could say, somewhat short of elation. While global health programs managed to escape Obama's federal spending freeze, critics were quick to point out that at just 2.6%, the increase for HIV/AIDS funding was less even than what occurred under the Bush administration. Especially given fears that the global recession will cause donor funding for HIV/AIDS to plummet, a U.S. commitment is more vital than ever. What's more, new World Health Organization standards for anti-retroviral treatments mean HIV/AIDS programs are going to be expected to do much, much more -- with potentially a lot less.

Still, though, all this fear of 'crisis' may be somewhat overblown. In fact, now could be a real opportunity for countries to commit to streamlining their programs for better results.

After you get through the usual academic wonkery, one article recently published in the Journal of Acquired Immune Deficiency Syndromes, "Financing the Response to HIV in Low-Income and Middle-Income Countries," sheds some worthwhile light on the subject. The authors' conclusion is startlingly simple, but prescient: "The most striking finding is the mismatch between the types of HIV epidemics and the allocation of resources." Translated: Money is being spent in ways that aren't in the best interest of at-risk and HIV-positive populations.

Specifically, the authors note, less than 1% of expenditures in countries with generalized HIV epidemics actually goes toward "addressing most-at-risk populations." To really stem the virus's spread, countries need to focus their efforts on the most-at-risk (and often most-stigmatized) populations -- from drug users to men who have sex with men -- while also stepping up prevention efforts, with a focus on more effective treatment.

As the article authors point out, many low-income countries are almost wholly dependent on foreign donors and governments to fund their HIV/AIDS programs. But if foreign donors scale back (or don't scale up quickly enough, as critics accuse the United States), the commitment of the countries actually facing the epidemics will undergo some much-needed scrutiny: How much of their own budgets are they willing to commit to this effort, and what's the most effective use of funds?

These are tough decisions, and every country's answer will vary according to circumstance. But they're crucial questions to ask -- ones that will allow governments to listen and directly respond to their people's needs, particularly those of at-risk populations. Far from being an unmitigated disaster, plateauing levels of funds can encourage officials to institute greater levels of oversight, with a lower tolerance for failure.

Sure, we'd all like as much money as necessary for all prevention and treatment to be available, but especially in the current climate, that's just not going to happen. Instead, governments should take stock of where they stand, and make the hard choices that will deliver the best results.

Photo Credit: roel1943

A Growing Global Health Corps

Te-Ping Chen — 2010-02-05T14:10:00-08:00

Jonny Dorsey is on a quest. As the 20-something co-founder and executive director of the Global Health Corps, he's working with a team of just four full-time staffers to produce an ambitious goal: an ever-growing network of young leaders in the fight for global health. Global Health Corps is a relatively new organization -- founded just two years ago -- but already it has 22 fellows in the field, each paired with different health organizations across Rwanda, Tanzania and Malawi. The idea to incubate a global network of leaders that will eventually number in the thousands and weigh in with a serious policy voice, as well as boots on the ground.

The group may be young, but it's clearly tapped into a strong current: its inaugural round of fellowships attracted over 1,000 applications. As Global Health Corps gears up to recruit its second class of 34 fellows, Dorsey spoke with Change.org via phone this afternoon:

In some ways, Global Health Corps seems modeled on Teach for America -- was that the inspiration?

Originally, we did first pitch this idea as a kind a Teach for America for global health. They've created a path for talented young leaders to get into education, and built a community around them to support continued careers in that space. So certainly, what they've done is a great inspiration. We also looked at City Year quite a bit -- they do work that combines tangible service with community building and leadership development that I think is absolutely amazing.

So apart from the obvious difference in mission, what makes Global Health Corps' approach distinctive?

Something we're trying to do that we think is innovative is make this is a really global fellowship. We send out our fellows in teams of two -- an international fellow and an in-country fellow -- who are genuinely equal partners. In Rwanda, for example, it'd be a young American with a young Rwandan, and in Malawi, it'd be a young Malawi with a young American. We also have six fellows who work in the United States, too -- four in Newark, NJ and two in Boston. In those situations, the U.S. fellow is the in-country representative.

So we're working to build a global community that can make the fellowship much more meaningful and deep. I love it. Because if you want to talk about building a new generation of leaders in health, it has to be global. We need leaders working in global heath in the U.S., and on the country level around the world. It's the only way to help strengthen this movement in the direction it needs and to take on these challenges.

Global Health Corps sends fellows to work with groups from Partners in Health to the Clinton Health Access Initiative. What kinds of skills are your partners looking for?

It's clustered around a few areas. There's definitely a need for help with technology and [information technology]. With groups trying to work on electronic medical records, managing IT systems is a major area of need. Supply chain management, too. A huge problem organizations face is how to manage the massive influx in medicine they get, and how to get it out to patients without overstocking it in certain health centers and having it expire, or running into shortages. Particularly with anti-retroviral drugs, breaks in treatment are really bad for patients, so managing the supply of drugs is really important from both a patient care and financial standpoint.

Can you share one story about the impact GHC fellows are making on the ground?
One of our fellows, Jafari, is working in Zanzibar. There's just one central medical store there where all the drugs from donor countries come in, but there are more than 100 clinics in Zanzibar that serve as distribution points for patients. Before Jafari arrived, all management was done on paper, and there wasn't really a system to try and forecast what was going to be used. So Jafari has helped them build a system using Excel. It's not some crazy complicated system, or it wouldn't be useful, but they're going to pilot it at a few different clinics. It's really exciting stuff to see.

For readers who might be interested in applying, what's the background of a typical fellow?

They come from all sorts of backgrounds. Peace-building, development studies -- some have MPHs. A few of them came out of the private sector as well, which we're really excited about. One fellow had worked at Gap with their supply chain, and now he's working with the Clinton Health Access Initiative. The types of roles for fellows really range: we need people who can do computing science for programming, but we need people with more of a managing background -- for example, to help Partners in Health build out their human resources strategy. We want to recruit people with a very diverse background. It makes our community more rich.

What kinds of organizations do fellows work with? At what level?

We're working with organizations at both ends of the spectrum. For example, in Burundi, we're working with Friends Womens Association, which was founded during the war by a group of women, some of who were widowed in the war. They wanted to provide health services to their community, and it's as grassroots as you can get, a really beautiful story. Our fellows are going to help build a tracking system for their patients, helping them aggregate outcome data to create a stronger partnership between them and the government.

On the other side, we'll have fellows working with the Clinton Health Access Initiative in Burundi as well, helping advise the government on how to better utilize nurses in Burundi. That's their primary charge. So, by contrast, they'll be working on the highest government levels, advising on policy that will affect millions of people in Burundi.

Your application deadline for U.S. candidates is coming up this March 1, and for international candidates, the month after. What would you tell people thinking about applying?

This is more than just a job. We're really excited to recruit people who want to devote a big chunk of their lives to working on global health and social justice, and want to be part of a community that's doing the same.

For more details on Global Health Corps, and to apply, visit their website here.

Photo Credit: desevilla

Haitian PM: Enough Hoopla Already About the Missionaries

Te-Ping Chen — 2010-02-05T08:54:00-08:00

It's got all the hallmarks of an old-fashioned media feeding frenzy. The paparazzi swarming the car, the sunglassed celebrities inside. The waves and waves of media hits (over 6,900 articles this morning), the nonstop cataloguing of blow-by-blow developments. (Which, if you've been sleeping under a rock, look something like this: 1). Group of Baptists gets arrested in Haiti for trafficking 33 kids over the border, 2). Group claims they were trying to help orphans, 3). Most said 'orphans' actually turn out to have parents, 4). Group has been jailed and charged with kidnapping, and the judge in this case has three months to decide whether to prosecute. Oh yes, and the New York Times has found out that the group's ringleader owes back pay to previous employees....etc.)

It's not so much scenting blood in the water -- enough blood has been shed in Haiti for the past three weeks, and plenty of it (c.f. Anderson Cooper) has been caught on camera. And covering logistics, sanitation and tent shelters is less appealing. So this time the cameras are on the scent of something else -- something much more titillating. Something much more...blonde. (Or, to be perfectly accurate about everyone involved, brunette.) No wonder the Haitian Prime Minister is throwing up his hands. He's just announced that the death toll has risen to 212,000. He's got a wave of one million people on his hands who are homeless, and an impending threat of water-borne diseases to deal with.

And yet the case of the pony-tailed, be-hatted Baptists is what has the media agog.

"I believe it's a distraction for the Haitian people because they are talking more now about 10 people than they are about one million people suffering in the streets," PM Jean-Max Bellerive says.

It's a distraction for people trying to understand what's happening in Haiti, and how best to help, too. As I wrote earlier this week, I get the native appeal of a story that can also function as a proxy morality play. And if it helps the Haitian government reassert its presence and authority, more power to them. But that's about it. At this point, apart from repetitive rehashing, what's there to add? We're very, very good at pretending every story is all about Americans, but tricking ourselves into thinking the story of 10 Baptist missionaries behaving badly is anything more than just a tangential one -- well, that's an even more accomplished delusion.

Photo Credit: blmurch

Finding Hope on World Cancer Day

Te-Ping Chen — 2010-02-04T12:26:00-08:00

Between its associated pink ribbons and races for the cure, for years, cancer has been seen as a disease particular to the industrialized world. These days, though, the reach of cancer is shifting, and expanding with alarming speed into Asia, Africa and Latin America. Fortunately, there's still some cause for optimism.

Let's start with the bad. Currently, over half of all new cancer cases — as well as fully 60% of cancer-related deaths — occur in developing countries. The World Health Organization notes that cancer kills more people in the developing world than even AIDS, tuberculosis or malaria. As a disease, in much of the world, cancer remains largely "undereported, undiagnosed and untreated," says David Kerr, co-founder of AfrOx, which works with African countries to implement cancer control programs.

Not bleak enough for you yet? Cancer is already the leading cause of death worldwide, and the number of deaths it causes is projected to rise 45% by 2030, partly because of the growing and aging population. Experts say that by 2020, the cancer death rate in low- and middle-income countries will vault to five times that of the industrialized world.

Those are some terrifying metrics. But what if you knew that someone had already invented a drug that was proven to cure 40% of all cancers?

Because that's effectively what we have already, says David Hill, who heads the International Union Against Cancer (UICC). According to UICC and the WHO, out of the 12.4 million cancers diagnosed and 7.6 million cancer deaths worldwide, fully 40% are preventable.

There's a certain fatalism that people tend to attach to cancer. Today, though, UICC is making World Cancer Day by fighting that attitude, in a new campaign called "Cancer can be prevented too." Sure, in the U.S., most kids have it drilled into their heads from an early age that smoking can cause cancer. But that's not all. Poor diet carries a serious risk, too, as do heavy alcohol intake, exposure to the sun and infections. (Both cervical and liver cancer are caused by infections, and can be prevented by vaccines.)

Right now, women in developing countries make up fully 80% of cervical cancer cases. What's the good news? These are cases that, if diagnosed early, can be treated. In the U.S., for example, the five-year survival rate for women who get treated early for cervical cancer is 92%. Likewise with breast cancer, the second-leading cause of cancer death in the developing world. Here in the U.S., fully 81% of women with breast cancer are still alive five years after diagnosis.

Treatment and prevention: not the most magical-sounding couplet, and they won't grab as many headlines as a cure for cancer. But if they can save 40% of people whose lives are stalked by the disease, their possibilities are nearly as revolutionary.

Photo Credit: SuperFantastic

Why the IMF Keeps Lending to Haiti -- Really

Te-Ping Chen — 2010-02-04T08:55:00-08:00

Over on Huffington Post, Daniel Altman has written a fascinating and, I think, pretty important post that helps get at a question that in all likelihood has been knocking around in plenty of people's heads of late. That is, leaving explanations of "excessive Scrooginess" aside, why would the IMF ever make a loan (and not a grant) to an impoverished country like Haiti, especially now?

Sure, the IMF gets a bad rap, and it's easy to paint the agency as a Western puppet armed with evil folios and grand aims to keep the developing world permanently in check. It's a pretty catchy narrative. It's also one that elides a lot of recent history.

Last year alone, global institutions -- including the IMF -- offered Haiti some $1.2 billion in debt relief. Over the past decade, the push for debt relief has garnered massive support, including that of the World Bank and IMF, which have joined others to reduce the burdens of heavily indebted countries. In just the past two weeks, the IMF has also come out emphatically in favor of debt relief for Haiti -- even as it's simultaneously proceeded to make the country a $100 million loan.

What's going on?

The IMF's managing director explains that the IMF simply lacked a speedy way to make a grant in the immediate aftermath of Haiti's quake. "The question was: were we going to do nothing -- or give a loan?" says Dominique Strauss-Kahn. "We decided to give a loan." Which the IMF is says it's now working to cancel.

The deeper question, though, remains: why lend at all? The answer, according to Altman, comes down to two things -- politics, and arithmetic. For donors, giving a loan -- even a low-interest one with a 50-year repayment period -- feels good, and doesn't the same clammy associations the word "handout" does. It also feeds the attractive notion that the country you're loaning to will succeed enough to repay you.

Why do poorer nations buy into the game? If you're facing a choice between a smaller donation or a larger loan, which would you choose? Well, if a country isn't the most politically or economically stable -- and presumably it isn't, because it's taking the loan -- the odds are probably low that 1). the same government will even be around when the creditors come calling and/or 2. that the government will be able to repay it at all. So why not take the loan? As Altman puts it, it's "[more money] to play with, with almost no strings attached."

I'm in the camp that debt relief is valuable -- enough so that you should definitely sign ONE's petition pressuring the US Treasury to help drop Haiti's debt. But as David Roodman argues elsewhere in a compelling case, it's hardly the most urgent priority that Haiti faces right now, so don't stop there. Currently, donations to Haiti have begun to trail, with contributions to the American Red Cross alone having dropped by 50%. Debt relief is important, but sustaining recovery efforts with continued donations may be the more pressing concern, especially as cameras in Haiti continue to leave.

Photo Credit: matthewbradley

A Second Chance for Clinton in Haiti

Te-Ping Chen — 2010-02-03T16:09:00-08:00

As of this afternoon, it's official: former President Bill Clinton has been appointed the UN's chief aid and reconstruction coordinator for Haiti. UN officials are crossing their fingers that Clinton can exert his legendary charisma to help attract the long-term attention Haiti needs. So far, countries from Canada to the Democratic Republic of the Congo have pledged some $2 billion, but relief efforts remain grievously uncoordinated.

What a long, strange trip it's been. As a man who held the title of UN special envoy to Haiti even prior to the Jan. 12 quake, Clinton's connections to Haiti are both contradictory and deep. While in the White House, Clinton backed a brutal embargo agains Haiti (with the goal of weakening the military regime that in 1991 had unseated democratically elected populist and President Jean-Bertrand Aristide). The embargo put Haiti in an effective straitjacket, destroying much of its economy -- in just a few years, Haiti's manufacturing sector shrank from 100,000 to some 17,000 workers. (Clinton later sent the U.S. military into the country to restore Aristide to power.)

Also in the 1990s, his administration kept 300 Haitian, HIV-positive refugees incarcerated at Guantanamo Bay, stuck in an extralegal camp with eerie semblance to today's base. Even as the Haitians staged hunger strikes to draw attention to their plight, Clinton fought in court to keep the Haitians in legal abeyance, despite the fact that they'd been declared refugees from the regime that had ousted Aristide.

Now, he's in charge of remaking the same country he turned his back on for years -- a country that's lost 200,000 of its citizens, with one million made homeless, and its government literally leveled.

Are there second acts in American lives? Clinton's been handed one such immense chance, and responsibility. In years past, he's expressed tremendous remorse for the consequences of his past actions in Haiti. With such a noisy set of foreign-policy ghosts trailing him, he has the extra burden -- and hopefully, drive -- to lead the world in helping rebuild Haiti.

Photo Credit: greekchickie

How Serious is U.S. Commitment to Haiti's Government?

Te-Ping Chen — 2010-02-03T11:37:00-08:00

On the one hand, you could see it as a scramble for political cover. After all, the U.S. has taken some serious fire over its handling of aid delivery in Haiti -- what better way to sidestep that argument than by strenuously affirming U.S. collaboration with President Préval?

Still, though, at yesterday's press briefing, it was refreshing to see USAID administrator Raj Shah take every opportunity (and then some) to emphasize U.S. efforts to partner with the Haitian government on the ground.

Maybe U.N. Deputy Special Envoy to Haiti Paul Farmer's message, delivered last week before the Senate Foreign Relations Committee, had gotten through. Or maybe (possibly?) the U.S. has started to sober up after its long, conspicuous track record of failure in Haiti (well-documented by the National Academy of Public Administration in a 53-page brief, titled "Why Foreign Aid to Haiti Failed").

Usually, attempts to hedge about donor failure overseas can take the form of an awkward kind of fan dance. Not so with Haiti. Multilateral donors have been incredibly frank about their lapses in Haiti (though failures could hardly be overlooked, considering that even before the quake, Haiti was 25% poorer than it was in 1945). Even the World Bank sums its track record up quite baldly, calling the effect of its assistance to Haiti since 1986 "negligible."

Why the failures? After reviewing the evidence, NAPA finds that shortcomings in aid "likely originated because donors collectively failed to address Haitian politics and governance as the important drivers of success, from which everything else would follow." They're not alone in that conclusion, either. According to the World Bank, without improved governance and institutional reforms, the Bank and other donors "will be able to accomplish very little."

Those are no uncertain words. Yet even with all the State Department's encouraging rhetoric on government engagement, I'm not convinced. Money talks. And right now, with less than a penny of every Haiti-bound dollar of U.S. aid going to Préval's government, it sure looks like the White House is still sitting on its hands.

Photo Credit: US_Air_Force

On Misguided Faith in Haiti

Te-Ping Chen — 2010-02-03T08:40:00-08:00

Talk of God infused much of the immediate post-earthquake commentary on Haiti, from Pat Robertson's foul claims about the disaster's origin to moving descriptions of how Haitians' faith remained upright, even in the rubble. Now, the latest installment of the God-in-Haiti narrative comes in the form of 10 American Baptist missionaries, recently arrested under charges of kidnapping 33 Haitian children to traffic across the border into the Dominican Republic. (The missionaries say they thought the children were orphans.)

Without knowing more about their intentions, it's hard for me to see these missionaries as particularly vile -- more like very, very misguided, and unusual probably only in the sense that they actually got caught (and triggered global headlines, and a diplomatic incident...and all that).

On Monday, Prime Minister Jean-Max Bellerive described the Americans as "kidnappers" who had known "what they were doing was wrong." Well, maybe. I think the more terrifying description of the group, and in some ways more damning, was that they thought what they were doing was right.

You can see it in missionary Laura Silsby when she tells the cameras in her Haitian prison cell, "All we know is that God is going to bring us to positive closure and we're just waiting for that answer...we are trusting God," as another 20-something missionary wearing a baby blue "Camp" t-shirt stands near by. Or in the words of their church pastor, Clint Henry, who says the group's intentions were "upright and pure."

How poisonous is naiveté, and how far will the argument "We meant well" (or God was guiding us or some derivative thereof) get you? In many ways, those are the baseline questions surrounding recovery efforts in Haiti right now, as the desire to do good runs up against uncertainty about how to effectively deliver aid. So even apart from the obvious drama of blonde U.S. missionaries getting locked up in jail for snatching Haitian children, there's a particular resonance to this story that I think goes beyond that immediate punchline.

Wherever the moral answer to that question lies, it's clear that on the ground -- which is the only place that anyone seeking to assist in relief efforts should be consulting -- the missionaries' actions didn't help anyone, and in fact made the situation worse.

Prior to the quake, there were some 1,700 career missionaries on the ground in Haiti, certainly not all of whom regarded Haiti as a "spiritual sandbox in which to frolic," as Bryan Schaaf puts it so memorably, and many of whom were doing good work. But the fact is, any pervasive framework or faith is going to shield you from certain facts about a situation, whether we're talking about campaigners who seek principally to expiate the West's past deeds in Haiti, or missionaries trying to recklessly force-feed Haitian children into Christian homes. As a motivator, faith may be an amazing force, but for policy purposes, it's a dangerous one.

Photo Credit: Goldemberg Fonseca

Lessons the Developing World Shouldn't Learn From U.S. Healthcare

Caitlin Cohen — 2010-02-03T07:04:00-08:00

There are a lot of things that developing countries might learn from the US healthcare system…in particular, what not to do for health financing. After all, when compared to other countries, the U.S. has the lowest life expectancy per dollar spent.

Part of this comes down to how we pay to access healthcare. For years, people have debated the effect of co-pays or user fees on patients. Proponents argue that user fees stop people from unnecessarily overusing healthcare services, while also creating revenue generation for health facilities and a sense of “investment” in health that will encourage people to take better care of themselves. By contrast, opponents feel that user-fees and high co-pays provide incentives for people to seek care too late, thereby increasing overall costs. (For example, treating bronchitis early is a lot cheaper than treating pneumonia late.)

A number of economists have found that in the U.S. healthcare system, increased co-pays do curb unnecessary health use, reducing costs without reducing health outcomes. (For more on this argument, you can check out NPR Planet Money podcast #143.) However, a Medicare study just published in the New England Journal of Medicine deals this perspective a major blow. In fact, the Medicare study shows that doubling co-pays lead to worse health outcomes and more expensive care overall.

The number of opposing conclusions out there can be perplexing. My theory is that co-pays might work to curb overuse in populations that already have sufficient access to healthcare, but (unsurprisingly) they also discourage people in populations that under-utilize care. Older people covered by Medicare already face transportation, mobility and emotional barriers to seeking care. Poorer people already feel the financial stress of even small co-pays.

How is this relevant to the developing world? Well, in 1987, the Bamako Initiative -- written by many of Africa's health ministers -- posited the idea that all healthcare users should have to pay some small fee for care, even if a nominal one. What's more, many developing countries are starting micro-insurance programs (often called “mutuelles”) that can help people access care, but also raise the tricky question of co-pays.

As this Medicare study suggests, strategies that force patients into a co-pay system need rethinking. Higher co-pays don’t work if limited access is the problem, and can in fact create worse health outcomes overall, ultimately costing more money. Rather than reinventing the U.S. health care system by promoting mutuelles and user fees, more countries should be considering streamlining and reducing out-of-pocket patient costs. In the long run, that's not only the most financially viable option -- it's also the most humanitarian one.

Photo Credit: ShellyS

Missing Latrines in Haiti

Te-Ping Chen — 2010-02-02T15:51:00-08:00

From a distance, it's hard to comprehend the challenges of securing sanitation for those made homeless after last month's earthquake in Haiti. But one vivid account from the Associated Press offers a narrow window into what relief workers are up against.

Just across the street from the gutted National Palace, a camp of some 2,000 earthquake survivors has access to a lone portable toilet. Most are compelled to use the gutter that runs nearby, squatting beside vendors cooking food and women bathing their children.

And they might be the lucky ones. While the UN has started to dig latrines for 20,000 people, that's less than 3% of the 700,000 people officials estimate are currently living in camps. More permanent resettlement camps are in the works, at least some of which will be equipped with plumbing and sewage. But in the meantime, doctors are bracing themselves for a sanitation crisis they fear could provoke a further onslaught of malaria, cholera and other diseases.

Already, some hospitals report that fully half of the children they're treating have malaria, even though the rainy season (when the mosquito population peaks) doesn't begin for several months. The Haiti clinical director for Partners in Health, Dr. Louise Ivers, says she's worried about a "mass outbreak of measles, which would really be potentially devastating for a camp where there are 10,000 people living."

Currently, only 292 latrines have been constructed, or are under construction. The UN Office for the Coordination of Humanitarian Affairs reports that some 7,000 latrines are needed.

What could those latrines look like? Jason Turgeon, over at Haiti Rewired, shares a run-down of the different kinds out there that could work, from pit latrines to anaerobic digesters. He concludes that for much of Haiti, composting toilets might be the best solution. They're easy to construct, comparatively odorless, and don't require water -- virtually all you need is a 5-gallon bucket. Over a year's time, following composting, the waste's volume shrinks by as much as 90%, becoming a valuable fertilizer that can be used in agriculture -- a much-needed commodity in a country with ravaged topsoil.

In fact, some of the technology's best ambassadors are already in Haiti: Sarah Brownell and Sasha Kramer, two Americans who've been on a mission to help with in-country sanitation efforts through the Haiti-based nonprofit they formed in 2006, SOIL. They're both eloquent conveyors of the belief that addressing Haiti's sanitation issues can mean a path toward greater agricultural sustainability, as well. It's inspiring stuff, and deserving of a second look. Check them out, in a quick-hit video documentary with Nicholas Kristof, here.

Photo Credit: sustainable sanitation

The Case for Pooling Donor Funds in Haiti

Te-Ping Chen — 2010-02-02T13:44:00-08:00

It's not exactly throwing stones, and especially after some of the uglier fallouts that have followed emergency fundraising drives, the American Red Cross must be feeling some measure of relief. But this article by Stephanie Strom, on whether relief organizations should take a closer look at a different model of fundraising -- pooled donations -- is a much-needed injection into the debate on how fundraising has unfolded in Haiti overall.

Consider this: Prior to the quake, Partners in Health had over 700 doctors and nurses in Haiti, out of a staff of nearly 5,000. They were running a hospital, as well as multiple clinics. By contrast, the American Red Cross had just 15 people in Haiti when the quake struck.

Since Jan. 12, which organization do you think has been able to raise more money?

Okay, okay, hardly a fair or surprising contest. The Red Cross, naturally, pulled in some $200 million to support its efforts in Haiti, and Partners in Health just one-fifth of that amount.

But it's hard not to ask, as Strom does, how organizations doing exemplary, on-the-ground work can find better support in times of crisis, especially when competing against those that command considerably more star power.

We've written extensively about how donors can try and target the most effective organizations in Haiti. Obviously, though, despite our fondest wishes, expecting every casual donor to try and navigate the maze of nonprofits out there isn't a realistic ask (tools like Charity Navigator, itself the subject of considerable critique, not withstanding).

One better option when disasters strike, as Strom describes, might be the creation of a fund that pools contributions -- a fund that, in turn, gets distributed among groups by an advisory panel.

There are all kinds of knee-jerk reasons be skeptical about this kind of model: greater levels of bureaucracy, questions over who would decide on distribution, et cetera. But other countries have put it into good practice, including Canada and the U.K. It's even been used on a smaller scale here in the U.S. -- for eg., with the Hope for Haiti telethon, and to a limited extent after Hurricane Katrina. In fact, after the tsunami, the Red Cross itself acted as a sponsor of pooled funds, contributing nearly half of the $581 million it raised to other organizations, such as the World Food Program. And in Haiti, the Red Cross has started down a similar path, by again committing $30 million to the WFP.

As for concerns about how the process might slow down the delivery of aid -- well, as has so often been cited in the past few weeks, Haiti's reconstruction process will be one that gets measured in years, not months. If the international community is committed to supporting relief efforts for the next 10 years -- as donors pledged in Montreal last week -- it also makes sense to think carefully about who they'd want to invest in for the job.

Photo Credit: david.nikonvscanon

Obama's Global Health Budget a Mixed Bag

Te-Ping Chen — 2010-02-02T08:45:00-08:00

Once the eyes adjust to the overall $3.8 trillion sticker shock of President Obama's just-released budget, for global health advocates, the proposal represents something of a mixed proposition -- neither unalloyed good or bad.

First, the good news. To begin with, the budget increases funding for global health initiatives by 9% -- up to fully $8.5 billion. Obama's budget also tries to straddle a more balanced sense of policy, with a focus on building up health infrastructure. In fact, the White House's budget more than doubles aid for tropical diseases, and in a nod to the key role women play in the fight for global health, ratchets up funding for child and maternal health by nearly 30%.

Tropical diseases such as hookworm, elephantiasis and trachoma, after all, are the neglected stepchildren of the global health movement. In fact, they're so darned neglected they get their own acronym to call attention to the fact: NTD. The World Health Organization estimates that one-sixth of the world's population are afflicted with one or more neglected tropical diseases. So kudos to the White House for increasing their attention to the issue.

Other provisions of the budget are far more lackluster.

For one, the proposal cuts support for the Global Fund to Fight AIDS, Tuberculosis, and Malaria by $50 million over levels supported by Congress for 2010. Meanwhile, Obama is requesting only a 2% increase in funding for the President's Emergency Plan for AIDS Relief (PEPFAR). And for tuberculosis -- a disease that last year killed over 1.8 million -- the White House is requesting an incremental increase of just $5 million over 2010 funding. What's more, the Centers for Disease Control's TB program will be cut by over $1 million.

The ONE campaign has produced a report card for the administration that ranks its global health budget on various counts, which gives the White House two "excellents" and four "insufficients."

So far, Obama's come out swinging with a number of impressive global health goals, such as leading the fight to end malaria deaths by 2015. But if he has any intention of making good on his promises, his latest budget falls far short of those ambitions.

Photo Credit: marcn

Somali Pirates Jump into the Fray in Haiti

Te-Ping Chen — 2010-02-01T12:32:00-08:00

Since Haiti was stricken by an earthquake on Jan. 12, the unlikeliest of casts has assembled to assist in the relief process. In addition to the usual gallery of public and private sector donors, there's the 7-year-old boy from the U.K. who's fundraised tens of thousands of dollars by cycling around his local park. There's the group of community health workers in Rwanda, who each make less than $200 a month, but nonetheless managed to fundraise $7,000 for their colleagues in Haiti.

And now, entering stage left, comes perhaps the scene's most unexpected addition of all: Somali pirates.

That's right. The same pirates who've enthralled the media for the past year, and even found themselves slotted into an episode of South Park. They're now announcing their intentions to give generously to the Haitian cause, and with pirates last year managing to attack 214 ships and hijack 47, it's likely the group is pretty flush with dough.

Evidently, it's not just a question of a Robin Hood-style transfer of loot, either. "The humanitarian aid to Haiti cannot be controlled by the United States and European countries; they have no moral authority to do so," says the Somali pirates' spokesman. "They are the ones pirating mankind for many years," says the spokesman. (That's a depressing discovery: even pirates these days have spokesmen, too?)

I'm not immune to the theatrical appeal of a pirate ship cruising down to Haiti, flag fluttering, to deliver supplies in a rakish kind of gambit. But as much as I'm gratified by the prospect of, say, UNICEF fighting shoulder-to-shoulder with pirates to deliver aid, I don't see much coming from these headline-hugging desperadoes' latest announcement.

The pirates say they have some kind of underground global network that will "help them ensure the delivery of aid without being detected by the armed forces of enemy governments." Huh. (Aside: I'd like to see Aid Watch have a field day trying to go after that one.) Really, Somali pirates? The tagline writes itself: If you liked unaccountable Western aid, just wait until you see ours.

Photo Credit: thornj

Rebuilding the Haitian Countryside

Te-Ping Chen — 2010-02-01T11:14:00-08:00

In the aftermath of Haiti's quake, myriad explanations have been rallied to explain why the devastation wreaked by the disaster was so vast. Poverty, years of government immobility, decades of debt, a legacy of Western oppression -- the list goes on.

Equally important, if more pedestrian, is yet another factor: population flow. Over the past three decades, Haiti's countryside has experienced an exodus, with massive numbers of migrants moving to the capital. Since 1980, Port-au-Prince's population has swelled to 3 million -- this in a city that, according to the Guardian's Ed Pilkington, was never designed to properly house more than 400,000 people.

Why the rural-to-urban flow? One of the voices we've been highlighting in the debate is that of Brian Concannon, who's worked for years alongside Paul Farmer as the executive director of the Institute for Justice and Democracy in Haiti. Concannon cites the manufacturing-driven course of economic growth that Haiti arrived upon, assisted by outside consultants from the World Bank and U.S. "In order to get the labor force you needed for assembly manufacturing, you needed to move people out of the countryside," he tells Change.org. He also points to the influence of U.S. trade policies in the late 1980s, which inundated Haitian rice farmers with cheap rice grown by heavily subsidized American farmers, decimating the local industry.

At the same time, Concannon says, "There was a general government disinvestment in the countryside." Schools deteriorated, as did basic farming infrastructure. Accordingly, people came to the cities to seek work, and in many cases wound up living in rickety hillside shanties. "They’re unsafe, and people living there know that," Concannon says, "but they have to put a roof over their families' heads."

This week, voices as distinguished as the New York Times' editorial board are calling for Haiti's reconstruction process to focus on development in rural areas and new, smaller towns. One promising idea on the table is a kind of "green-collar" program for Haitian nationals, which would create jobs to plant trees and restore topsoil. Both are goals that would not only inject much-needed cash into the local economy, but also help remake some of the countryside in a way that would reduce its vulnerability to natural disasters.

Already, tens of thousands of survivors have streamed out of Port-au-Prince into the countryside since the quake -- into towns like Petite Riviere, for example, which has already seen its population double in size. Meanwhile, the government is planning to make refugee villages outside of the capital, each housing 10,000 survivors. After any disaster, whether and how survivors should be resettled is always a source of contention. But in this case, there are real reasons to think that for many Haitians who have left the capital, a better life might mean not going home.

Photo Credit: M Eriksson

Cell Phones as Political Tools for Haiti

Te-Ping Chen — 2010-02-01T07:30:00-08:00

Has the role of cell phones been exhausted in Haiti's relief and recovery efforts? So far, they've been used to raise an unprecedented $30 million via text-message donations. They've also been invaluable on the ground: as Nathaniel has documented over at our Social Entrepreneurship blog, social innovators like Ushahidi, to take one example, have been effectively deploying the technology to crowdsource information in Haiti throughout relief efforts.

The media has prominently featured both these trends, with the fundraising role of cell phones receiving particularly extensive play. (For more information on how text messages have been used to locate and treat survivors, you can check out Wired's able coverage here.)

But cell phones have also played another, less remarked-upon role in the aftermath of the quake. Mobile technology has been a potent political tool, helping thousands mobilize pressure for action on Haiti.

Reform Immigration For America (RI4A) has made particularly good use of the technology. During uncertainty over whether the White House would grant a temporary stay on deportations for undocumented Haitians currently living in the U.S., RI4A supporters responded with thousands of phone calls driven by text messages. (Joined by activists around the country, the campaign was ultimately successful.)

What does a text-driven lobbying campaign look like? Chrissie Brodigan offers a quick run-down of RI4A's strategy:

1. The group texted its supporters a brief message: "Immigration Alert:1000's of Haitian undocumented immigrants risk deportation 2 Haiti. Call Obama, ask 4 Temporary Protected Status NOW! Pls Forward"

2. The text message also included a toll-free number to call, 866-930-3396, which RI4A set up to patch through to their target's phone number. (The backend routing can be handled by an outside firm, for e.g., Mobile Commons.)

3. While supporters' calls were being transferred, a 30-second "script" was aired to prep the caller on what to say.

4. After the call was made, RI4A sent a "thank you" text, encouraging supporters to forward the message or get more involved.

The best way that activists can help Haiti during recovery efforts may be a matter of some controversy, with groups like ONE calling for debt relief, and a vocal minority arguing that such efforts would be better spent elsewhere. Whatever the ‘ask,' though, from debt relief to allowing more Haitian immigration, there are plenty of way for activists on Haiti to make themselves heard, and greater use of mobile technology shouldn't be left off that list.

Photo Credit: samantha celera

What Could the iPad do for Global Health?

Caitlin Cohen — 2010-01-31T07:45:00-08:00

Critics say the iPad is just an overgrown iPhone. But in its defense, an overgrown iPhone turns out to be a pretty useful thing -- one with some real possible implications for global health. Like any other tablet computer, it can be used at a bedside in the same way a clipboard could be, but with major advantages. Periodically, the developing world “jumps the technology gap,” for example, by skipping from no telephone connections to cell-phones without cumbersome landlines in-between. So what could tablet computers like the iPad do to help the medical field leap-frog past the electronic growing pains?

1. There is a Wikipedia movement abreast to make open-source digital textbooks that could be used to train new physicians. In the wake of the earthquake in Haiti, the U.S. National Library of Medicine, for example, is making health journals available to help with the response. As a U.S. medical student I am blessed with instant access to lots of shiny books and the internet, and I can't imagine learning medicine without these resources.

2. If you have ever tried to read a doctor’s handwriting, you understand the plight of the pharmacists of the world. Electronic resources for medicine dosing (such as Epocrates) and electronic prescribing can cut down on amazingly frequent medication errors, such as giving a patient Lodine (an arthritis medication) instead of Iodine (an antiseptic). One Dutch study found the mean number of medication errors to be 55%, a figure that was reduced to 17% after switching to electronic prescriptions.

3. In France, you hand a doctor’s office a small card with a chip on it, and that chip allows them access your entire health history. This kind of innovation in electronic medical records has the potential to drastically improve patient outcomes. New groups like Frontline SMS Medic are looking at ways to make text messaging and EMRs integrated and user-friendly for the developing world.

4. In Mali, there are new “telemedicine” programs to share patient imaging, like x-rays, over the internet. The iPad doesn’t yet have a camera feature, but in the future it likely will. Imagine being able to take photographs of a patient’s skin rash and share them in real time with a dermatologist several thousand miles away. In Mali, patients are responsible for their own images, which means that they are often crushed or lost. An iPad would let a physician scroll through consecutive MRI slices or x-rays over time and see what changes.

Of course, this little iPad fantasy is a few years off -- a clinic would need good cell reception and affordable data plans that could compete with the cost of a paper-based system. The iPad itself would need physical protection and repair. But as we consider the cost versus quality within the U.S. health care system, why not help developing countries jump the technology gap and implement a system that's both more efficient and medically effective?

Photo Credit: monumen91