Monday, November 19, 2007
The entire experience in Kwazulu-Natal was amazing and full of learning experiences. It was like nothing I had experience before and I was astounded by how different it was from Cape Town. I was impressed by the health clinic that was in a rural area, but am curious how such a small place could service such a huge population.
For me the most remarkable part of the entire excursion was when we went to the school to help out. A lot of people were painting a classroom, which was a tremendous help to the school. There was also a group of four people, and then five, that were going to help teach the educators how to use the new computers they had. Someone had generously donated around eleven new computers to this rural school, but unfortunately did not train these teachers on how to use them. My expectations were that we would come in and teach them how to do things on Microsoft and Excel and get them up and running. I had not even thought about the fact that most of these women had never even seen a computer before. Instead of jumping right in like I had thought I first had to teach them what a keyboard was and basic things on it, how to move the mouse and double click. It was more difficult then I had envisioned because I have been using computers for so long it is like second nature. I had to keep remembering that they did not know what I mean when I said ‘shift’ or ‘enter’.
The first woman I was teaching was getting very frustrated with the whole thing. She was a fast learner but was having trouble with the mouse. The man that was helping us kept teasing her about her typing, while it was meant in good fun, made her even more self-conscious. At one point she asked if she could leave the room and get some fresh air. It was so difficult to try and sit down and teach these women how to do all the things on computers at once. It was so much information for anyone to handle. It made it even more difficult that this woman did not speak English well and was also not used to my accent. The bell rang and the next group of teachers came in. I was feeling a bit frustrated from the one before but I was still eager to help in any way that I could.
The second woman that came in was much more excited to be learning about the computers. She picked up on typing and the mouse really quickly and then we started to work on Microsoft Word. I sincerely believe that this woman changed me in a profound way. She was so happy to learn how to type in math problems and sentences to make a worksheet. I taught her to save and found what she saved in ‘My Document’. When she found it and clicked on it without my help and found her document there she was so happy, in a way that I cannot even explain. I felt what every teacher must feel like when a student is excited about learning, but in a way I felt like this was more then that. I had done something for her that a lot of people could have done, but had not yet. When we discussed Altruism in the class the other day we were just discussing whether it existed or not. In that moment it seemed to me, why would you want it to? I helped someone out but got something so profound out of it that I could never imagine going in somewhere and helping him or her without getting any sort of benefit from it. This entire time I have been trying to decide how this ties into Public Health. I think that by teaching these women a new skill I was helping to empower them. They now know something that they can teach others, which by nature gives them more power. Whether this happens or not, empowerment can help them to make better health related decisions. They can feel more confident to make their partner used a condom, to take their kids to the health clinic, or even to leave an abusive relationship. By having computer skills, it opens them up to a whole new realm of knowledge that they have not had before. I am not saying they are now involved in a western way of thinking, but more like they can now adapt computer skills into what they are going to need the most. In this one morning I did not teach this woman the computer inside and out, but I have her the confidence she needed and the excitement to learn more about it.
Wednesday, November 7, 2007
Excellent films end with the viewer asking more questions than the film itself answers. Born into Brothels is no exception. The documentary touches on a multitude of complex topics: the role of religion and the caste system, dense urban living pattern, discrimination against certain social sectors, HIV/AIDS transmission in at-risk communities, and the struggles poor families face in their efforts to keep their children in school. It’s impossible to write about all these issues within the space of a single journal entry. For the sake of clarity and substance, I will stick towards the first issue, the role of the caste system in India.
The issue of religious privilege is raised in subtle ways throughout the documentary. There is the astute observation by one of the young female photographers, who herself comes from a Brahmin family, that a private school might only serve vegetables to its students. This, of course, would be a step back for a child who is regularly accustomed to eating chicken and other sources of protein. Implicit in the child’s questioning is the social positioning of her family and, by consequence, her family’s position in the Hindu hierarchy. Zana, the narrator, acknowledges this reality when she articulates her concern for the nutrition and general well-being of the other children, who by the narrator’s own admission are, by default, not Brahmins.
A variant of the caste system rears its head in the film when the narrator discusses her difficulty in procuring a passport for Avijit. The caste system is an engrained system of discrimination veiled behind religious platitudes. The refusal to issue Avijit a passport because his parents are mere criminals, by virtue of their professional occupation, highlights a deeper issue, the larger discrimination that certain sectors of the Indian community face. The obvious victims are sex workers and less obviously, those suffering from HIV/AIDS. When Zara attempts to enroll the young photographers in a boarding school, the principal demands HIV/AIDS tests as a precondition for acceptance. Implicit in that scene is the idea that individuals suffering HIV/AIDS are contagious and undeserving of a proper education.
Against this backdrop, the recent government of Prime Minister Manmohan Singh has sought to advance an affirmative action policy targeting the most marginalized sectors of the Indian community, namely the untouchables. Over the last few years, quota systems have been instituted in higher learning and government job vacancies. There is, of course, a glaring omission, the private sector. The rise of the IT sector in India- and, by consequence, the corporate rise of firms such as Infosys and Wipro- has empowered a whole new generation of young college graduates. Yet, such job growth and employment has not been uniformly distributed across society (on a side note, it’s ironic to realize that the ongoing debate concerning black economic empowerment, quota systems in higher education, skilled labor, and ownership of productive capital is not just occurring in South Africa). It’s on the heels of the aforementioned statement that The Economist penned an article entitled “With reservations” that described veiled threats the Indian government was leveling against the private sector to increase employment of dalits and Other Backward Classes (OBCs), segments of society considered to be the lowest rung of Hindu priestly society. The article itself was an articulate and persuasively argued piece that sought to make the case against dalit and OBC affirmative action in India. The report raises some key questions and observations that deserve to be studied more in-depth (perhaps more means-testing is needed to fine tune and target the most socio-economically disadvantaged groups). That being said, I think the Prime Minister’s threats are accomplishing something, from a public policy perspective, because it is forcing the private sector to develop its own programs to train and employ greater numbers of employees from disadvantaged backgrounds. At least in that sense, the Prime Minister’s words are being taken seriously by private companies. A failure to incorporate greater number of disadvantaged Indians in the economic boom that is presently befalling Indian risks alienating a sizeable percentage of the electorate and, by consequence, any future support for liberalization reforms.
I selected this piece not because of its relevance to the film, but also because it touches on a subject that is regularly debated here in South Africa, namely economic empowerment for the most marginalized communities. It also deals with a subject that perfectly fits with this week’s theme of children. At the root of any debate concerning private sector and higher education affirmative action, is a population of young adults who ten years ago were just children.
Wednesday, October 31, 2007
By Alison Duncan
“Brain drain” is a phrase which has come into common use in recent years, as it refers to an issue which is of increasing importance throughout the developing world, particularly on the African continent. The issue interests me because it has a huge impact on the functionality of many countries’ economic, educational, and health care systems. The case study represented here, by Malawi, is paralleled in countries all over the world. I found it particularly interesting to compare its situation in Malawi to that of South Africa, a much wealthier nation in the same region. Without ever explicitly stating so, the article challenges our society to find a solution to this growing problem which is often overlooked when considering health care challenges and crises.
This article was printed in the South African newspaper The News and Guardian and addresses the brain drain crisis in Malawi, though the issues brought up are by no means exclusive to that country. It starts out by giving a personal story of a Malawian nurse who has decided to leave her home country in order to make more money in Britain. Cases like hers are becoming increasingly common in Malawi, according to the article, where an estimated 120 registered nurses have migrated to Britain and the United states every year for the past ten years. The article implies that this brain drain is due to salary, stating that the “Health Ministry is unable to even begin to match the wages on offer abroad.” Malawi’s crisis is particularly acute because there is such a need for health professionals given the HIV/AIDS epidemic in that region, which makes it all the more upsetting when those who are able to provide services choose to leave.
The article notes that “14% of the country’s population is infected with HIV,” and that it has only “56.4 nurses and 2 doctors for every 100,000 potential patients.” This is well below the World Health Organization’s recommended minimum of 100 nurses and 20 doctors per 100,000 people, and that recommendation does not take into account the added strains of such a large population infected with HIV. By comparison, South Africa has 393 nurses and 74.3 doctors per 100,000, which is more than adequate. In the rural areas the crisis is at its worst, with a vacancy rate for nurses at 60% according to a survey by the Ministry of Health.
Interestingly, Malawi’s government recognized the problem three years ago and “launched an emergency plan… which saw health workers receive an average 52% pay rise… and aimed to strengthen training capacity, repatriate professionals and fund recruitment of foreigners.” The Malawian Health Minister Marjorie Ngaunje noted that “there are serious problems…Malawi needs to train 1000 nurses annually if we want to arrest the situation.” She pointed to the necessity of increasing intake at nursing colleges as a primary solution. Doctors without Borders is concerned that the Malawian government’s plans to provide free anti-Aids drugs are going to be compromised given the healthcare worker shortage. They are quoted as saying that “it is evident that the rapid scaling-up of ARV therapy… will be limited by non-availability of adequately trained nurses, clinic officers and doctors.” In all, the article convincingly illustrates the severity of the problem and the urgency with which it must be dealt.
I always associate the issue of the brain drain with the healthcare worker shortage because the two are directly and inextricably linked, as the Malawi case clearly demonstrates. The cyclical nature of the brain drain is underscored all the more by Malawi because of the exacerbating effects of the AIDS epidemic there. Essentially, healthcare workers leave to get higher pay, which shortens the staff in over-crowded hospitals and clinics, which then causes healthcare workers to leave in order to recognize a pay increase and escape the pressures of being short-staffed, which makes healthcare workers want to leave, and so on. To my mind, the key to solving this problem is not to get bogged down in the cyclical parts of being short-staffed and over-worked, but to tackle the primary cause. This article suggests that a desire for an increase in wages is the main causal reason that nurses and doctors leave their countries. If this is true, then it seems obvious that the salary discrepancy between countries must be eliminated and benefits drastically increased. I was also struck by the idea that healthcare professionals in these countries are seemingly no longer satisfied with their jobs intrinsically, because they are seeking extrinsic benefits overseas as opposed to within their own countries where they could be of greatest help. In my opinion this is a very big problem, as it indicates a decrease in healthcare workers’ genuine interest in administering aid to needy patients. As far as dealing with that issue, I am not sure what the solution is, or even where to begin. If our healthcare providers are no longer interested – at their core, regardless of pay – in providing healthcare, then we are indeed in trouble: not just Malawi or other developing countries suffering from the “brain drain,” but the world as a whole.
Monday, October 29, 2007
By Alyson Zandt
On a recent weekend, the Weekend Argus ran an article entitled ‘Youths at forefront of Joe Slovo protests.’ This article is chronicling the involvement of the youth in last week’s N2 Gateway protests by residents of Joe Slovo, the informal housing settlement named for perhaps the most famous white activist in the Anti-Apartheid movement. The government is currently implementing a plan to advance the economic situation of communities directly alongside the N2 highway. This project has two primary goals: to improve the circumstances of the numerous residents of informal settlements flanking the N2 and to make Cape Town more appealing to tourists and international investment. The N2 is the main thoroughfare between the airport and the city, and as a result it is the first impression of Cape Town that visitors have.
Because the government would prefer investors and tourists to view development rather than abject poverty upon arrival, a plan was developed to move residents of communities out of their shacks so that formal housing could be built in the area. As the article discusses, this means uprooting an entire community and moving them to a less desirable area. When the formal housing is completed, there will not even be enough room for everyone to return. Today I was in an informal settlement in Atlantis. Despite the housing backlog, the informal houses are slowly being replaced by government houses. In this case, the residents remain in their informal homes until the formal housing (just on the other end of the settlement) is completed. This would not work in Joe Slovo because there is no undeveloped land nearby for the government to build on, but it does show that not all removals are so negative for the residents.
The N2 Gateway Project has been in the works for several years now, and it has been in no way secret. Only recently have the protests begun, despite the awareness in Joe Slovo of the planning that was occurring. The reasoning for the recent uproar is unclear, but it could stem from the shift in government priorities. There was a program withtin the Office of Social Development that was tasked with communicating with those that would be affected by the N2 Gateway Project, but it was halted with the change in the local government. Since one of the problems is the residents of Joe Slovo not being informed of the process and another is that the government is unclear of the specific concerns and realities of Joe Slovo residents. Another possible reason is the current national tide of protests which began in Soweto and have spread to other urban centers.
This article was particularly interesting to me because I was inadvertently caught in the middle of the thousands gathering to go to the Cape Town High Court. They choose to march towards the court after gathering around the Phillip J. Sauer Building downtown—which just so happens to be where my office is located. Walking out of your office to be greeted by a mass of thousands of angry (but decidedly composed) protestors is a tad disconcerting. I found myself curious to know more about their reasons for gathering, but as a lone white female (and employee of the City) I thought it best to make my way through the large and intimidating crowd and continue on my way.
The connection to health of this situation is obvious—conditions in informal settlements are unsanitary, hazardous, and conducive to a variety of diseases and health risks. However, mental health is often overlooked by the development field, and the strength of community felt by Joe Slovo residents should not be disrupted without due consideration. Additionally, the proposed move to Delft will carry with it new heath concerns. The residents raise concerns about the cold and transport. Because of the more difficult transportation system in Delft, the youth would not be able to reach school or employment as easily. This means more down time and the loss of their support network, which increases risky lifestyle choices.
This situation has taught me a very important lesson about development—your view of progress as an affluent outsider is not necessarily shared nor is it always correct. While it is important to fight against poverty, traditional methods such as providing formal housing are not automatically the best option. It is essential to make sure that the people involved in orchestrating development (whether it is the government, civil society, or private interests) must emphasize communication and dialogue with the people ‘benefiting’ from the development. Culturally important aspects of peoples’ lives, such as a strong sense of community, should not be undervalued.
Wednesday, October 24, 2007
By: Jillian Casey
October 4th, 2007
This article came as old news to me as word around the office was already buzzing about the cancellation of Merck’s vaccine trials. The only piece that was new was the aura of an overwhelming loss that I have not perceived here in the HIV-fighting community of South Africa. The Desmond Tutu HIV Foundation was already almost a year into the vaccine trials when the plug was pulled and defeat admitted by Merck and infectious disease experts alike. To my amazement, I have yet to witness any surprise or disappointment from my colleagues at work. There are no gray clouds over anyone’s heads, no gloomy faces, and not even a whisper of acknowledgement of the loss this community has just incurred. It makes me wonder: What faith does the developing world, and concomitantly, the populations most ravaged by HIV/AIDS, instill in vaccine trials as the potential knight in shining armor to slay this human predator? I can’t help but suspect that defeat was actually expected at the DTHF, and for that reason, the news was not received as defeat at all. What I really want to know is why.
The New York Times article, Failure of Vaccine Test is Setback in AIDS Fight, embodies the disappointment and frustration of the Western World in the war on AIDS. I have to wonder why American journalists, multinational Big Pharma executives, and western medical culture as a whole, are more distraught over the failure of Merck’s drug than are the very people who witness the devastation of HIV/AIDS on a daily basis. Granted, I have not had the opportunity to pay a return visit to the DTHF’s vaccine trial center since the cancellation of the trial, but I would still anticipate a more heartfelt reaction from those in the head office (who are running the show) than I have thus far observed. In fact, upon questioning a few coworkers, I have even discovered that many of them are not aware of the response or the impact this has had on the organization or the HIV community at all.
So how can this be? The best answer that I can come up with is that on the ground in South Africa, where almost a quarter of the population is infected with HIV, there is no time to waste hoping for a successful vaccine. The doctors and medical professionals here cannot wait years for the approval of a vaccine because people are dying by the day. Parallel to the argument that those who live in poverty can only afford to think of today, so too must the doctors who work for the impoverished focus their efforts on the present. To expend energy on vaccine trials, and therefore divert energy away from ARV treatment by impact of opportunity cost, one is jeopardizing the lives of those already infected. In the developing world, where resources are stretched to exhaustion, the dream of an HIV vaccine can only be entertained with promise of outside funding and staff so as not to pinch the pockets of the already under-funded treatment programs in existence.
Even still, when funding is provided by the NHVTN (National HIV Vaccine Trial Network) from the States, and PEPFAR has leant money for the staffing and supervision, how then can the doctors closest to the cause not feel a surge of distress when they learn that another effort has failed? Perhaps it’s because it is the very doctors who are so involved who can understand and appreciate the gap between our understanding of and our ability to eradicate this virus. Doctors know that HIV is a biologically simple virus; they know that it can be prevented and even treated. But they respect that we are a long way from grasping how to vaccinate against it, and so they leave that task to those with the time and money to take on such a challenge. They let those who do not have to listen to the coughs of dying parents and look into the faces of children who are soon to be orphans on a daily basis worry about the long-term struggle.
Perhaps these assumptions are entirely inaccurate. Perhaps I am just struggling with my own romantic hopes of a vaccine versus my practical plans for life-saving today. I can say that being in South Africa, and working for an organization participating in the trials when a promising vaccine is pulled, has not at all produced the response I would have expected. As time goes on, I suspect I will find a greater understanding of why such setbacks are received so differently across cultures. I often feel as if I am just an outsider here, window-shopping through the confusing streets of South Africa’s public health network. But this lens lends me the benefit of seeing things from a more patient eye, one that can project into the future because my today is not so desperate. In talking to the doctors at the DTHV, I see in their eyes that nothing has changed since the cancellation of the trials. Tomorrow, like today, they will again face patients whose CD4 counts are plummeting and whose T cells are being assassinated by opportunistic infections. Either way you like to look at it, they are either not as fortunate, or not as naïve as me and my western counterparts in their investments in an HIV vaccine initiative.
I can only hope that these seemingly separate communities can merge at some point and the vision of tomorrow can be reconciled with the reality of today. Because even though a vaccine would undoubtedly be the most valuable development in the global campaign against AIDS, it is important to remember that treatment and education cannot suffer in the name of a prospective solution.
Monday, October 22, 2007
by Deborah Bender, PhD, MPH
Dr. Rose Jallah Macauley, WHO Coordinator of Routine Vaccinations and New Vaccine for the Africa Region, visited Cape Town to share her expertise with UNC Honors Students this past week. Dr. Macauley, an alum of the UNC School of Public Health, received her MD from the University of Liberia and an MPH from the Department of Maternal and Child Health in 1987.
The focus of her remarks was on the Global immunization Vision and Strategy (GIVS) developed by WHO and UNICEF for 2006-2015. The GIVS sets a number of goals to be achieved by 2010 and another set by 2015. The immunization coverage goal for 2010 is that all countries will attain 90% DPT3 coverage at national level and 80% in all districts.
For the past 4 years African countries have be implementing the Reaching Every District (RED) approach to improve and maintain high immunization coverage. The 5 operational components of the RED approach (Re-establishing outreach services, Supportive supervision, Linking with the community, Monitoring and use of data for action, and Planning and management of resources) were chosen to re-energize immunization delivery in the Africa region and to provide management infrastructure sufficient to enable local districts to reach their targets.
Dr. Macauley reminded her audience that measles mortality reduction remains very important in Africa. The GIVS Measles Mortality Reduction Goal which challenges countries to reduce mortality attributable to measles by 90% by 2010 as compared with 2000 levels. The strategies being used to attain this goal are: Catch-Up campaign, Follow-Up Campaign and Keep-Up Campaign. The Catch-Up Campaign which targets infants and youth up to 15 years of age is unique in global health strategy because of its extended the age limits.
In addition to the measles mortality reduction, Dr. Macauley also spoke about other accelerated disease control initiative, including polio eradication initiative, yellow fever control and maternal and neonatal tetanus elimination.
The polio eradication initiative has 4 strategic areas: strong routine immunization achieving >90% OPV3; supplemental immunization activities (NIDs, SIDs, Mop ups). WHO and it partners have focused major efforts in Nigeria, the only polio endemic country in Africa, to interrupt the transmission of wide polio virus. While great progress has been make in reducing the number of wide polio virus cases, there still have been isolated reports of the occurrence of vaccine derived polio virus (VDPV) cases reported in Nigeria. Risk factors associated with the VDPV in Nigeria are said to include: Low routine immunization coverage, poor sanitation, over crowding and the tropical condition.
With regards to the introduction of new vaccines, over 80% of African countries have introduced Hepatitis B vaccine while about 50% have introduced Haemophilus influenzae type b vaccine.
Dr. Macauley reminded the audience that childhood immunization is one of the most successful and cost-effective health interventions ever. During the 1980s, under John Grant’s leadership at UNICEF, vaccination rates reached new high levels. However, during the 90s, during the years when the global funding shifted priorities (e.g. combating of the emerging HIV/AIDS crisis), vaccinating the world’s children took a back seat. Immunization coverage either stagnated or decline in most countries in Africa. Estimates are that 2.5 million children under five years of age die every year as a result of diseases that can be prevented by vaccination using currently available or new vaccines. Dr. Macauley expressed confidence that the innovative integrated approach of the GIVS Strategy will achieve its 2010 and 2015 targeted goals.
Saturday, October 13, 2007
I met Mirriam Goa at National Heritage Day. She heard from a mutual friend at the gathering that I was a public health person and, immediately, she introduced herself to me. She told me that she was a public health nurse and that I must come to visit her program, Ilinge Lokuphila, in the
Yesterday, I went to visit Mirriam. The Township lies 20 minutes outside of
Mirriam stops mid-sentence to add – these problems, --the isolation of the elderly -- they are caused by people, by these people’s own children not coming to care for their parents. This is to say, that in African culture not caring for one’s parents is almost unimaginable. But, today, despite Mirriam’s sense of disbelief, this is happening.
When Miriam or one of the volunteers makes a home visit, they sometimes uncover other unexpected problems. Sometimes a daughter has left her children with her elderly mother to go to work. Other times, it is more difficult; the children may live permanently with the elderly relative because have been orphaned by AIDS, which has taken a parent’s or parents’ lives. The hardest for Mirriam to accept is that some of her elderly, themselves, have contracted HIV/AIDS through being unaware of protective precautions necessary when caring for an infected adult daughter or son.
It is hard to talk about AIDS, she tells me, because there is still a lot of stigma associated with the disease. People infected with the disease are often forced to leave their homes and shunned by friends. So, no one talks about the disease, and the disease is left to spread silently through the community.
The home visiting program is vital to the community, but Mirriam wants more. She would like a larger space where community members could meet and share a noon-day meal. She would like to use the same space to create a support group, to help people infected with HIV/AIDS and their families. “Now,” she explained, “If a daughter discloses, she’ll tell her mother first above all. But, often her mother will deny what her daughter has told her. It is just too hard to accept.” Mirriam believes that people need a place where they can learn about the disease, and where they can learn how to talk to one another about AIDS. “The way to take apart the stigma is to talk about it – to talk about it directly, “she added parenthetically.
Mirriam says that TB is also a problem in the community. Again, sometimes people do not take their medicines. But, in this case, Mirriam thinks that it is the doctors who prescribe the medicines who do not understand the community well enough. One of the volunteers made a follow-up visit to the home of a man who did not return to the clinic for his TB meds. The volunteer asked him why he did not come. He answered, simply, “The doctor told me to come back for my medicine after I had eaten. I haven’t eaten. That’s why I didn’t come.”
Mirriam and the other women of Guguletu, the volunteer home visitors, are busy. They work from 9 to 5, and sometimes evenings, too. Still, there are more homes they would like to be able to visit; meeting space to be negotiated with the City of Cape Town; and, additional services to be offered. A garden promotion program would help in providing improved nutrition and needed micronutrients for community members. She also imagines creating a park with swings for the children to play in. A crèche for the very young children right next to it would be ideal. "We have a long way to go," Mirriam concludes as other volunteers in the room nod in agreement.