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Archives for Global Health

Turning the Corner on HIV and Tuberculosis Co-infection in Brazil

AIDSTAR-One is funded by USAID’s Office of HIV/AIDS. The project provides technical assistance to USAID and U.S. Government country teams to build effective, well-managed, and sustainable HIV and AIDS programs.

A patient at the CECAP Clinic in São Paulo receives his TB medication from his doctor. Photo Credit: Ed Scholl, JSI

HIV and tuberculosis (TB) affect millions of people worldwide every year. Eighty percent of the world’s cases of HIV are concentrated in the 22 countries—including Brazil—with the largest TB epidemics. Without precise and sustained treatment, HIV and TB can become a deadly combination for men, women, and children.

Adolescents like 17-year old Silvia (name has been changed) from São Paulo need access to medical services to treat both TB and HIV. I met Silvia last November, when she came to a clinic to seek medical care for multi-drug resistant tuberculosis (MDR TB)—a dangerous form of TB that requires special medical care and treatment.

With funding from the U.S. Agency for International Development (USAID), which provides support to medical clinics throughout Brazil for TB and HIV services, Silvia is receiving the care she needs to lead a full, healthy life.

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Empowering Communities to Help Eliminate Female Genital Mutilation

Today is the International Day of Zero Tolerance for Female Genital Mutilation and Cutting (FGM/C). Worldwide, 100 to 145 million women have been subjected to this practice, which can range from nicking the skin to a total removal of the external female genitalia. Every day, 6,000 girls are at risk.

In Guinea, a woman receives training in problem-solving skills as part of USAID-supported efforts to encourage communities to abandon female genital mutilation. Photo Credit: Elizabeth Fakan, USAID

Zero Tolerance Day is an opportunity to raise awareness about the harmful effects of FGM/C and unite communities around the world in calling for an end to the practice. FGM/C is practiced across cultures and religions—though notably, major religious doctrines do not mandate the practice. It is most common in Africa, the Middle East, and some countries in Asia. However, it also can be found in the United States, Europe, and other places where migrants bring their cultural traditions with them. Parents and communities practice FGM/C based on cultural beliefs about health, hygiene, and women’s sexuality. In many cases, it is considered a traditional rite of passage.

However, research has consistently shown that all forms of the practice harm women’s health. It causes serious pain, trauma, and frequently severe physical complications such as bleeding, infections, or even death. In the long term, it can also lead to recurrent infections, infertility, and difficult or dangerous childbirth that threatens the lives of both mother and infant.

Since the early 1990s, USAID has supported FGM/C abandonment efforts. In September 2000, the Agency officially established the elimination of FGM/C as part of its development agenda, and issued an official policy and strategy on the topic. The single most important aspect of ending this practice is involving the community. USAID focuses on enabling and empowering communities to make their own collective choice to abandon FGM/C.

For example, in West Africa, USAID has provided support to the Tostan project that incorporates health and rights information about FGM/C into a basic education curriculum that also teaches problem solving, math, and reading. As a result, thousands of villages in eight African countries in both West and East Africa have publicly abandoned FGM/C and other harmful traditional practices over the past 15 years. Another program in Senegal, called the Grandmother Project, has focused on empowering grandmothers and other elderly women to lead community discussions and call for change.

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Dispelling Family Planning Myths in the DRC

“Are family planning methods safe?” wondered Mutombo, a community health worker at the Kawama Village health center, in the Democratic Republic of Congo’s Katanga Province.  “Don’t they contain a poison?” he added, directing his question to Isaac Chishesa, a community mobilization specialist with USAID’s Democratic Republic of Congo-Integrated Health Project (DRC-IHP).

Isaac facilitates a group session on FP with health workers at Kawama Village Health Center. Photo Credit: MSH

Tough question!  One Isaac was not expecting, at least not within a discussion among trained community health workers.  An experienced community health professional, Isaac responded with a smile and said, “Thank you, my friend, for sharing your concern,” affirming the participants’ right to ask questions.  “Family planning methods are safe,” he then reassured the group.  “Based on international quality standards, each method is required to go through extensive testing before it is made available to the public.”

The faces of Mutombo and his peers lit up.  They sighed, a collective sigh of relief, and burst out laughing to relieve some of the tension.  They all recognized that even though they were dedicated to bringing about improvements in health behaviors, they, like most of their fellow community members, harbored misconceptions and rumors about family planning.

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Tackling Tuberculosis in Migrant Populations

On December 19, 2011, the day after International Migrants Day, I found myself on a plane from Almaty, Kazakhstan to Dushanbe, Tajikistan, for a business trip.  I was surrounded by Tajik laborers returning home to celebrate the New Year. Other than my three colleagues and I, the seats were filled with Tajiks bearing electronics, toys, and other gifts for their families.  Had it not been for my ignorance of Tajik or Farsi, I would have struck up a conversation with my neighbor to find out what life was like being separated from one’s family for work.  Instead, I reflected on my own family, descendants of immigrants not unlike my fellow passengers.

Migrants and medical officers discuss the TB situation in the region. Photo credit: Abt Associates,Tajikistan

On December 23, 1909, my 26-year-old great-grandmother, Auyoung Yee Lau, emigrated from China to Hawaii to join my great-grandfather, who had opened a successful shop in Honolulu.  Prior to his wife’s arrival, my great-grandfather sent home $45 each month to feed five adult family members.  I wonder what went through Auyoung Yee’s mind as she boarded the boat from Hong Kong to what she called “the land of the Golden Mountain.”  I would guess that her thoughts were on the unknown country she was about to make her life in and the three children that she had lost in recent years, two of whom died of preventable childhood diseases before the age of 3.

After my great-grandmother’s journey to America, her tragedy was overcome with the subsequent births of five boys, four girls, and finally, my grandfather, whose Chinese name translated into “Happiness Complete.”  Had my great-grandmother and her family been denied access to health care services in Hawaii due to their migration status, I wonder if my grandfather and his siblings would have suffered the same fate as Auyoung Yee’s first three children?  Would my great-grandmother’s happiness have been complete?

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Recognizing and Tackling Disrespect and Abuse of Women in Childbirth

A young mother lies with her newborn child. Photo Credit: UNFPA

When I started midwifery training decades ago in the United States, in the hospital where I worked, I first saw evidence of disrespect and abuse of women in labor. Women were separated from families and visitors from admission to discharge four days later and, in the second and third stages of labor, their legs were secured by stirrups and their wrists put in leather restraints.  Soon after, I worked in West Africa in a government maternity and witnessed women being verbally abused — “if you don’t push and your baby is born dead, it will be your fault” – and physically abused by slapping and massive fundal pressure to force delivery. Women were ridiculed for making too much noise in labor — and then were chastised if they were silent and delivered alone.

Fast forward decades later.  As I visit maternity services in a number of countries, I don’t need to look far to see and hear evidence of disrespect and abuse of women in childbirth.  A convulsing woman in labor on the steps of an urban referral hospital turned away from because she cannot pay.  A doctor who derides poor women for not using family planning to control their fertility.  A nurse who tells me that postpartum mothers “sneak in” to see their hospitalized newborns at night, while the families seek to find funds to pay the bills in order to get their newborns discharged.  Unclothed women laboring and giving birth as visitors walk by. A researcher who tells of a postpartum mother being detained for months because she could not pay her bill. The human rights worker who tells me that refugee women are discriminated against in childbirth and that one refugee was forced to keep her stillborn in her bed with her for 24 hours against her will.

I do not cease to be saddened and angered by the number of ways women giving birth are being degraded, abused, and humiliated by healthcare workers, often women themselves.  Abuses continue to occur in all corners of the world, including my own. They are not behaviors that are easy to change.  Some are reinforced by financial incentives and subtle or overt discrimination. For many, the behaviors are learned and reinforced in home, school and society — wherever there are unequal power relationships.

Despite the problems, many of the frontline caregivers at birth – midwives, doctors, nurses and auxiliaries – work diligently, treat women with compassion, and even use their own resources to assist women in referrals in the case of life-threatening emergencies. Their selfless work needs to be recognized, even while the problems of abuse are uncovered.

I am now very encouraged that the issue of abuse is resonating with so many who care for and about childbearing women.  I see there is growing attention to this problem through documentation of the abuses; identification, dissemination and the implementation of the new Universal Rights of Childbearing Women; and implementation research to expand the evidence base on what it takes to tackle this problem effectively.  Many people and organizations are working on this and I am delighted that the United States Agency for International Development is supporting this work in country settings, in partnership with many others, to ensure that all women are treated with the respect and compassion during childbirth that they deserve.

Originally posted at the White Ribbon Alliance blog

 

A Triumph of Coordination: To the Last Case in India and Beyond

Ellyn Ogden delivers a polio vaccine in Kolkata. Photo credit: CORE Group

Ellyn Ogden has coordinated USAID’s polio eradication initiative since 1997 and is a frequent visitor to India.

Western Uttar Pradesh was once seen as the world’s largest reservoir of polio virus. Four districts, namely Moradabad, Bareilly, Rampur and Badaun, were considered the ‘Hot 4’ and for many years, people speculated that the last polio cases would be from these districts. But the skeptics were wrong. The districts pulled together, involved all ministries, not just the health sector, and held everyone accountable for performance. The District Magistrates took charge and became personally involved in solving any obstacles that would crop up. Vacant medical officer positions were filled and progress was monitored closely.

Across India messages travelled the TV and radio airways. Celebrities and sports legends lent their support. Rotarians urged everyone to participate, provided much needed financing, and rolled up their sleeves to help out during the campaigns. CORE and UNICEF Mobilizers spent countless hours answering mothers’ questions, and in some places visited every pregnant woman to sensitize her in advance of the need for immunization. When the baby was born, the mother would then receive a ‘congratulations’ card, an immunization card and education on how to protect the child from a range of diseases. These extraordinary efforts make a difference far beyond polio eradication.

The last polio case in India was in Howarah District of West Bengal. It was not in the ‘Hot 4.’ It was in a child who was never vaccinated against polio in the routine system. It was in an unexpected area, demonstrating the importance of a robust surveillance system. The rapid outbreak response by the West Bengal government has been exceptional. The health team in the area knows how fragile the situation is. Still, far too many families refuse vaccination, there are periodic shortages of the trivalent vaccine used in the routine system, there are vacant medical officer posts, and routine immunization sessions happen once a month rather than the needed once a week in many rural areas.

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A Triumph of Coordination:  Eradicating Polio from India

Ellyn Ogden, USAID’s Worldwide Polio Eradication Coordinator, delivers oral polio vaccine to a child in Kolkata, India. Photo credit: CORE Group Polio Project

Ellyn Ogden has coordinated USAID’s polio eradication initiative since 1997 and is a frequent visitor to India.

The news out of India this week marking 12 months with no confirmed case of polio is indeed a landmark event.  I have had the good fortune of working with the Pulse Polio Program, as the Polio Eradication Initiative is called here, since 1997, and have seen firsthand the hard work and dedication of the Indian government at the national, state, district, block and panchaiyat levels.  Over 2 million health workers, mobilizers, and volunteers have contributed to this success and deserve to be seen as heroes in their communities.

There have been many challenges over the years, not the least of which was figuring out how many children under age five there really are in India.  When I participated in my first surveillance review in Bihar, there were no surveillance officers assigned yet and the eradication program was in its infancy.  Today, India’s polio eradication program and its surveillance system, the envy of all other polio eradication programs, is often cited as the model to strive for.

With the help of WHO, UNICEF and Rotary international, detailed plans are developed to assure that vaccine reaches every village, data is analyzed and feedback given to constantly improve the work of the teams.  Detailed maps help trace the daily route of the vaccination teams.  Supervisors provide guidance and quality control.  Monitors verify the work of the teams, by checking to see if their fingers are marked and flagging any locations with poor coverage.  Sweep teams go back to find missed children.  Issues are discussed at evening meetings during the campaigns and corrective action taken immediately.  Government accountability and ownership is very visible.

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Meet the Innovator: Jorge Odon

“Imagination is more important than knowledge.” –Albert Einstein

It all started with friendly bet amongst friends – who could get a cork out of an empty wine bottle with only a plastic bag? The friends had seen the trick on YouTube earlier and wanted to re-enact it.

Somehow, Saving Lives at Birth finalist Jorge Odon, an Argentinian car mechanic with no medical background, drew a connection between the trick and obstructed labor, which is a major contributor to maternal mortality.  The idea came to him in the dead of the night. Inspired, he woke up his wife to share his idea.

She told him to go back to bed.

Eventually, his persistence led him to patent the idea. He then worked with national and international partners to further develop a device that is now a reality and being tested. The Odon device is an example of human ingenuity and a keen ability to recognize the practical application of simple scientific concepts.

The Odon Device is made of film-like polyethylene material that can help facilitate the birth process and may provide a safer alternative than forceps and vacuum extractor for assisted deliveries. Moreover, in settings with limited surgical capacity and human resource constraints, it may be a safe alternative to some Caesarean sections since it could be used by mid-level providers or in facilities lacking the surgical capabilities for Caesarean section.

The Odon Device has potential for wide application in resource poor settings. If proven safe and effective, the Odon Device will be the first innovation in assisted vaginal delivery since the development of forceps centuries ago, and the vacuum extractor which was developed decades ago.  By reducing contact between the baby’s head and the birth channel, the device could also prevent infections acquired during delivery.

Visit Saving Lives at Birth for more information on this and other innovations.

Listening and Remembering: The Fight against HIV/AIDS in Kazakhstan

Recently, in commemoration with the 30th anniversary of the fight against HIV/AIDS, I had the opportunity to sit down with people who are on the front lines of this struggle in Kazakhstan.  Our informal press round table was a chance for people living with HIV to tell their story about discrimination and access to health care.  The discussion was lively, and each person had a different experience to share.  One thing everyone had in common was deep remorse for the lives lost to this disease.

A doctor, Gulzhan Akhmatova, shared the difficulties of getting patients to comply with their medication requirements and how this situation is improving dramatically.  Nurali Amanzholov, from the Kazakh Union of People Living with HIV, gave a strong overview of the many types of discrimination that HIV-positive and most-at-risk people face in Kazakhstani society.  Because infected individuals do not feel safe or free to disclose their status, they remain isolated and unknowingly continue behaviors that facilitate the transmission of HIV.  In this environment, the disease remains hidden and spreads.

I am sure there wasn’t a dry eye in the room when Vitaliy Vinogradov, an HIV outreach worker focused on the men who have sex with men population, shared his experience working with this at-risk population.  He spoke very personally about the loss of friends to HIV as well as the hate crimes that gay people face in Kazakhstan.  The official estimate of gay men living with HIV in Kazakhstan is 1 percent of the total infected population.  However, some NGOs estimate the rate is closer to 13 percent.

As Secretary of State Hillary Clinton brought forth in her Remarks in Recognition of Human Rights Day, we must continue to be leaders in the fight for equal treatment of all people.  I was honored to share a morning with people in Kazakhstan who are bold advocates for HIV-positive groups in their country, and I look forward to a renewed partnership with them in the fight to end stigma and discrimination toward people living with HIV in Central Asia.

Victim of Sex Trade Inspires Others to Adopt Healthy Behaviors

On World AIDS Day, I am reminded of a recent visit to Guatemala where I visited an old stretch of railroad called La Linea, which is now home to sex workers who rent tiny rooms for business each day.

Their business is a precarious one. The solicitation of sex in exchange for payment brings inherent and obvious health risks to individuals who engage in this behavior, but also for the community.  For those who make a living in commercial sex work, education is key to ensuring they are able to protecting themselves by reducing the risk of contracting HIV and other sexually transmitted diseases.

Guatemala’s HIV prevalence rate is less than one percent among the general population. HIV in this country is classified as a “concentrated epidemic”, because cases are generally much higher among particular groups of people. One in every twenty sex workers in Guatemala is HIV-positive. Programs that educate these at-risk women on how to protect themselves will be critical to the country’s ability to keep the epidemic from spreading beyond this group to surrounding communities.

I met with a peer educator named Noemi, who works with a USAID-supported education program that is implemented by a PSI affiliate in Guatemala.  Shunned by family after the death of her mother, Noemi was forced from an early age to fend for herself. At fourteen, her grandmother sent her away and suddenly she stood alone in the world.

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