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Sixth Annual Unite For Sight Conference: Insights and Innovations in Public Health

Posted By Prucia Buscell, Friday, May 15, 2009
Updated: Tuesday, February 15, 2011
Goals for a dignified and decent life on our planet have been enunciated three times in the last 60 years, and timetables and accountability are the only hope of achieving them, in the view of Jeffrey Sachs, an economist, professor and director of the Earth Institute at Columbia University.

In 1948, the Universal Declaration of Human Rights had profound significance around the world as people tried to recover from the ravages of World War II, Sachs said. In 1978, the Declaration of Alma-Ata proclaimed health as a fundamental human right. In 2000 the UN Millennium Development Goals constituted an international agreement to reduce extreme poverty, disease and hunger by the year 2015.

The goals have not been met, Sachs said, but the wisdom of the documents is still alive, and like all great documents they need to be renewed and refreshed by each new generation.

"The goals declared at the start of the new millennium were full of hope and renewal,” Sachs said, asserting that security, safety, health, and educational opportunity, as well as freedom from conflict and preventable disease, are basic human rights. Rather than defining poverty in terms of dollars, he added, the document recognizes that extreme deprivation is multi-dimensional and needs to be addressed in a multi-dimensional way.

It is inexcusable that nine million children die before their fifth birthdays, when nearly all of those deaths are caused by extreme poverty, Sachs declared, adding it is a disgrace that children die of malaria for lack of a $5 bed net, that women and infants die because of unsafe childbirth, and that pandemic, parasitic, infectious and controllable diseases cause suffering, blindness and death.

"We need to keep these goals alive, and hold leaders accountable. That is our most important tool,” Sachs said. "We need international leadership. The new world is multi-national, and any solution needs to be cooperative….We are networked. The joy of our time is that we can cooperate in ways we couldn’t even think about in the last century.”

Corporations, businesses, nongovernmental organization, universities, scientists, civil society and individuals can collaborate and create partnerships to find solutions, he said, adding that he sees himself "as a plumber, making connections across these areas, finding ways to make the pipes fit.”

Sachs was a keynote speaker at the Unite For Sight sixth annual Global Health Conference at Yale University April 18-19, 2009. Unite For Sight is a nonprofit organization founded to empower communities worldwide to improve eye health and eliminate preventable blindness. The conference drew more than 2,200 participants from 50 states and 55 countries and a multitude of disciplines, to exchange ideas in all areas of public health and international development. Presenters included physicians, nurses, professors, organizational development practitioners and workers and specialists from dozens of public health-related fields. The following summaries represent just a few of the presentations and discussions at this extraordinary event.

Idealism is Not Enough

Nicholas Kristof tells a cautionary tale about cassava farming in Nigeria.

He recalls that he and his wife worked on a farm where women were raising cassava they ate and sold. Their cassava bed had a low yield, so they welcomed the opportunity for a new variety of the plant that yielded five times more crop. But they didn’t have the time or equipment to harvest it all. Further, the cassava plants absorb mercury and arsenic in areas where it remains in the ground from earlier gold mining operations, and the plant itself has naturally occurring chemicals that trigger production of cyanide. So the increased processing was polluting the ground water. The crop, however, was making money, and men decided they should be in charge of a cash crop. So they took over the operation, and the women were left with nothing.

"Idealism is not enough,” Kristof said. "You need grass roots understanding. There is a danger of making things sound too easy. Ideas are easy. Acting on them is a difficult. And you need to learn form your mistakes.”

Kristof, the Pulitzer Prize winning New York Times columnist who has written stories about human suffering and courage in remote trouble spots all over the world, urges would-be activists, "When you think you know what’s happening, back off. Travel in grass roots areas, find a cause larger than yourself, and get out of your comfort zone. You have to be bewildered.”

Kristof addressed the Unite For Sight conference last month at Yale. People are sometimes dubious about whether aid interventions work, he said, but they are necessary and they can help. See his May 13 column "What A Little Vitamin A Can Do” to combat unnecessary blindness among people in Africa.

Grass roots efforts tend to work best, he said. Great effort has been expended since 1970 to reduce female genital cutting in Afghanistan, he said, but conferences and new laws have had little impact. What helped a great deal was getting girls to school. Politics also may not be helpful. In combating AIDS, he noted, conservatives want abstinence and liberals want condoms, but the most effective approach may be something else. Girls in school who have learned the AIDS rate among middle-aged men are less likely to become involved with "sugar daddies,” despite the economic pressures to find financial help from older men. Kristof was one of several presenters who observed that when girls are educated and women have more social influence, poverty declines. More money is spent on children and small businesses and less on alcohol, prostitution and other vices.

Years ago, Kristof said, a New Yorker donated $100 to educate bright girls in a Chinese village he had written about. The bank erred, and gave the village $10,000. On a return visit 15 years later, Kristof found girls’ education and scholarships continuing, and many more educated young women holding good jobs, starting businesses, and educating their siblings.

Infectious and Chronic Diseases: Today’s Health Threats

Susan Blumenthal, MD, a former US Assistant Surgeon General who is a professor at Georgetown and Tufts University Schools of Medicine, spoke of trends and changes, not all reflecting progress. In 1969, she said, the US Surgeon General declared the battle against infectious disease had been won. Today, she said, the greatest health threats world wide are infectious disease and chronic disease.

Since 1972, she said, more than 32 new infectious diseases have emerged, and 1,500 people die every hour world wide from infectious disease. When people and animals live in close contact, pathogens flourish, and modernization and international travel facilitates dissemination. Climate change and extreme temperatures also foster emergence of new diseases that are water borne, air borne, and carried by rodents and insects. She added massive forest cutting promotes lymes disease in humans.

"We need public health policy that focuses on chronic disease,” she said. "We need to combat childhood obesity: 24 percent of our kids are over weight, and diabetes is becoming epidemic.” Inactivity, which contributes to obesity, impacts every organ system in the body. She added that one fifth of American children are shorter than children of a decade earlier. Published reports have documented that Americans are no longer the tallest people the world.

Disease and "Socioemergence”

A collection of interacting economic, political and environmental processes over several decades may have facilitated the movement of the viruses, Simian Immunodeficiency Virus SIV and Human Immunodeficiency Virus HIV, from nonhumans to humans. Rebecca Hardin, PhD, an assistant professor at University of Michigan’s School of Natural Resources and Environment has studied "socioemergence,” the political and cultural dimensions of emergent viral diseases in Africa’s equatorial rain forest. From 1890 to 1930, she said, the area was under brutal colonial control, with forced labor drawn from small villages for logging and road building. Because the environment does not lend itself to raising cattle, workers were fed wild game. In later decades increased hunting and a growing trade in wild game meat was a threat to African wildlife in the Congo Basin, where the populations of chimpanzees and other primates plunged. Continued road construction from remote areas and human migration increased environmental pressures. Researchers found high HIV prevalence among women in commercial logging areas, and theorized that their vulnerability was related to the social and economic networks created by the industry. The Bushmeat Crisis Task Force website says wild game commercialization is a human as well as natural tragedy: loss of animals means endangered livelihoods and food insecurity for indigenous and rural populations most dependent on wildlife in their diet, and bushmeat consumption is increasingly linked to deadly diseases like HIV/AIDS, Ebola, and Foot and Mouth disease.

Mosquitoes and Malaria

Malaria is a preventable and curable disease that kills a million people a year, most of them children in Africa. Marcelo Jacobs-Lorena, PhD, a malaria researcher and professor in the department of Molecular Microbiology and Immunology at the Johns Hopkins School of Public Health, is seeking ways to increase the arsenal of weapons against mosquitoes. Mosquitoes bite an infected person, then pass the malaria germ to the next person they bite. Bed nets offer some protection for people sleeping. Insecticides bring resistance, Dr. Jacobs-Lorena said, and as soon as all the mosquitoes in an environmental niche are killed, more will come to fill the niche. A malaria vaccine does not yet exist. "We will never conquer malaria with a single approach,” he said. "We will have to do multiple things.”

Dr. Jacobs-Lorena’s research involves genetically modifying mosquitoes so that they will be resistant to the pathogen and unable to transmit it. That has been achieved, he said, and the next step, still being researched, is to spread the resistant gene to the rest of the mosquito population.

"Let the people Lead"

Pamela Lynam, MD, is country director for JHPIEGO in Kenya. (That’s pronounced Ja-pie-go-, and its one word, not an acronym.) In her Unite For Sight presentation she stressed letting people lead the way toward health in urban slums. By 2030, she said, three of every five people on earth will be living in cities, and 95 percent of urban growth is in the developing world. One third of all urbanites world wide live in slums, and 72 percent of African urbanites are slum dwellers.

The characteristics of slums, she said, include poor quality health care, lack of access to a hospital, lack of access to public services, good drinking water, and sanitation. "You’ve heard of the flying toilets of Nairobi? People use plastic bags and then throw them,” she said. "Sixty percent of the people live on five percent of the land. And officially, they are not there, so they have no rights where they live. No one has to supply them with water, electricity, or anything else.” Such conditions promote distrust between communities and health services that do exist, she said, with real issues of insecurity and neglect. Breakdown of traditional social structures in urban slums mean large numbers of HIV deaths, children given to neighbors, violence, and very sick patients.

The traditional approach to aid, she said, has been to have experts tell people what they need. The better approach, used by JHPIEGO and many others, is to let people define their needs, and have aid directed towards fulfilling the needs. For example, she said, in one large slum near Nairobi, an aid organization offered to bring people clean water, and was surprised to find what they really wanted. "People said that’s fine, we do want clean water,” Dr. Lynam said, "but first we’d like covered bus stops, because we get soaked waiting for buses to go to work.”

The community-owned JHPIEGO intervention included anti-rape training, peer education, a village health committee, and a community theater. A community garden is generating small income and better nutrition. A self-defense group made a map of their own community showing places where people can get medical help and counseling, and its members have helped victims of rape and other crimes file police reports so that suspects are charged. They have also traveled to other communities to help others address their local needs.

"Great things happen when people start to respect and appreciate each other,” Dr. Lynam said. "The key is having people come up with their own solutions, and building trust, which takes time and patience, as well as enthusiasm and energy. You have to have a local staff. Consumers do know their own health challenges, and the results are sustainable because they come from all stakeholders.”

Dr. Lynam added that monitoring and evaluating aid programs is a very big challenge that carries with it the need for flexibility from policy makers and donors.

Women as Change Agents

Educated, empowered women are society’s change agents and the key to community health, said Jill Lester, president and CEO of The Hunger Project, a non profit that fights poverty not by direct aid, but by mobilizing women and forming partnerships with government. The organization operates in eight countries, using an "epicenter strategy”, in which clusters of villages that have up to 20,000 people work together to improve health, education, sanitation, or start small businesses. "If a woman can earn enough income so that her family goes from one to two meals a day, it changes her relationship with her husband,” Ms. Lester says. "The whole family changes if the mother has enough money for her family to eat.” She described a group of women in Senegal used a small loan to begin manufacturing a vitamin supplement for children using millet and nuts. In the process they learned skills in nutrition, hygiene, marketing and finance. A women who was illiterate a year ago now takes pride in being able to read her Bible, have soap and water in her house, and handle money without being cheated.

Destruction and Building Back Better

The Chinese got it right, Neil Boothby says: Crisis does represent both danger and opportunity. The aftermath of the devastating Indian Ocean tsunami that struck just before Christmas 2004, killing more than a quarter of a million people, also brought some beneficial legal and social changes.

Boothby is a professor and director of the Program on Forced Migration and Health at Columbia’s Mailman School of Public Health, addressed a session entitled The Epidemiology of Human Rights. He has studied efforts to protect children and families in war and disaster, and described several positive changes that developed from viewing emergency responses through a human rights-based lens. For one thing, he said, the tsunami was a tipping point for cessation at the time of civil war in Sri Lanka and Indonesia In Aceh, an emergency response framework resulted in establishment of family tracing and legal changes to protect children. New laws banned children from leaving the country alone so that child kidnapping and trafficking was greatly reduced. Police patrolled bus stations and created special desks in police stations for women and children. Before the new laws, only eight percent of children accused of crimes had lawyers, so a child who stole a piece of fruit would receive the same treatment as one who committed a felony. After the change, 71 percent of accused youngsters were represented, and the rudiments of a juvenile justice system was begun. In addition, 82 percent of children who were separated from their families in the disaster were placed with families or reconnected with relatives as a result of a family search program. Under the old system, orphanages would recruit and pay families for bright children with good academic records. A large Muslim nonprofit organization that formerly supported orphanages is reexamining its policies.

In Sri Lanka, a proliferation of orphanages came to be viewed as a secondary cause of family separation. Government and non-government agencies have started finding ways to reduce institutionalization of children, and to create safe recreational space where large numbers of children can be reached with basic social supports. Social spending has been increased in Sri Lanka and Indonesia since the tsunami.

Violence Against Women

Marie Skinnider, MD, Health Advisor to Medecins Sans Frontieres/ Doctors Without Borders, Canada, described the "consequences of gender-based violence in Papua New Guinea,” which has one of the world’s highest rates of domestic and sexual violence. One of her patients, in the first trimester of pregnancy, was gang raped while walking across a field in mid-afternoon. She had returned to her parents’ home because of domestic violence, and it appeared her husband had arranged the attack as revenge for her leaving him. Dr. Skinnider cited national survey data showing 67 percent of wives say they have been beaten by their husbands, and 60 percent of men say they have participated in gang rape at least once. The violence, she said, is generated and reinforced by the low standing of women in society: women are regarded as property of their husbands, and there are traditions of bride price and polygamy as well as a history of compensation and retribution attained at the expense of women. These social forces contribute to men being pressured by their peers to control women in their homes. Many women do not feel empowered to seek medical help, Dr. Skinnider said, and lack of transportation also prevents many women from going to health clinics.

Liberation Medicine in Education and Action Toward Health For All

Lanny Smith, MD is Professor of Medicine in the residency program of primary care and social medicine at Montefiore Medical Center, Albert Einstein College of Medicine in The Bronx, New York. He sees patients from the Highbridge and Morrisania sections in the Bronx, communities that are predominantly Hispanic and African American and that have extremely high poverty rates. He is also assistant director of the Human Rights Clinic for Victims of Torture and founder and president of Doctors for Global Health. He explains that liberation medicine has its roots in theology, psychology, ethics, education and liberation movements. The clinic design is inter- and multi-disciplinary, community-oriented and bottom-up, risk-taking, compassionate, and uses a praxis—practice in action—model. Online resources include Social Medicine and the People’s Health Movement. In a discussion after his presentation, he stressed the importance of careful listening and action learning. He cited Daniel Levin, who was acting assistant US Attorney General when he voluntarily endured waterboarding to decide for himself whether it constituted torture. He decided it did and later lost his government job.

Tags:  buscell  change  complexity matters  innovation  leadership  medicine 

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