OpenForum – a blog by the Health and Human Rights community

[Editor's Note: This OpenForum op-ed was written by Abigail Hook, a Harvard College undergraduate currently volunteering with the FXB Center]

The wealth of global response to Haiti’s January earthquake suggests a tremendous sense of global responsibility for a country whose current death toll is over 200,000. Now that Haiti is on the world’s central radar, how might those involved in rebuilding ensure that Haiti become a lasting center of global responsibility? That is, what’s the relationship between empathy for those affected by disaster and an engagement in transformation?

Read more

[Editor’s Note: This two-part entry features a narrative and photo essay by Dan Schwarz. The entire photo series and Dan's bio may be found below.]

Founded on an unwillingness to accept the grave inequities and double standards that are tolerated every day within the world, Nyaya Health, a small NGO in rural Nepal, operates with a mission of health equity and social justice. Nyaya — which means “justice” in Nepali — founded much of their work upon the model of Partners In Health, taking a rights-based, community-based approach to health care delivery. This post tells the story of Nyaya’s work in Bayalpata, and lessons learned in developing a health system in rural Nepal. Read more

[Editor's Note: This photo essay by Dan Schwarz is accompanied by narrative, found in the post above.]

Photo 1: Sanfe Bagar Primary Health Center

Nyaya Health opened the first community free clinic in the district of Achham in 2008. During the 14 months of its operation, Nyaya’s all-Nepali staff of 20 full-time personnel saw over 17,000 patients, providing the first allopathic physician in a region of over 250,000 people. Nyaya closed the clinic and moved all operations to the nearby Bayalpata Hospital in 2009.

Photo 2: Bayalpata Hospital

Today, seven months after opening its doors, Bayalpata Hospital has a continual flow of patients, and is quickly gaining a reputation for being the best available healthcare in the region. As Nyaya continues to expand its services through its partnership with the Nepali Government, it aims to contribute to the broad-based development of a community health system, focusing on health equity for all in a region that has historically been one of the most marginalized in all of Southern Asia.

Photo 3: Dilapidated Bayalpata Hospital buildings

Having sat unused for nearly three decades in a region with little power, water, or transportation infrastructure, the renovation of the hospital has been, and remains, an extremely complicated process. Of the five original staff quarters, only two have been restored, the others far too damaged to ever be functional again.

Photo 4: Bayalpata Outpatient Department

Bayalpata Hospital sees, on average, ­50 to 60 patients per day in its outpatient department. Patients most commonly present with respiratory infections, gastroenteritis and diarrheal illnesses. All services, including Nyaya’s laboratory and pharmacy, are free.

Photo 5: Emergency department

Upon opening, Bayalpata Hospital became home to the first emergency room in the area, providing services around the clock. Patients’ families frequently carry their loved ones in on homemade stretchers, often walking for over 4 to 6 hours to reach the hospital. Beginning in 2010, Bayalpata Hospital will commence emergency transport services to larger referral hospitals in the South of Nepal, with the region’s first ambulance, a recent donation from the Indian Embassy.

Photo 6: Nyaya laboratory tech Drona Awasthi

By offering point-of-care laboratory services, Nyaya is able to provide top-quality healthcare despite the remoteness of Achham. However, in the winter, because of the poor temperature regulation of the concrete buildings of Bayalpata Hospital, our lab technicians frequently have to use portable heaters to raise the temperature of the equipment before turning them on to avoid causing damage to the machinery.

Photo 7: Staff quarters

In order to provide 24-hour emergency services, Nyaya’s on-call staff all live within the hospital premises. As there are not enough quarters for the entire Bayalpata staff, and because Achham is very rural, this means that other staff have to walk up to 2 hours each day, to and from work, to their homes.

Photo 8: Hospital generator system

Because the regional power grid is shut off for several hours each day (“load-shedding”), and often for weeks at a time altogether, Nyaya relies on generators and inverters to power Bayalpata Hospital. But even this remains complicated: because no skilled maintenance technicians exist in the region, when the generator breaks, it must be shipped across the country where trained personnel spend weeks fixing it, at great costs.

Photo 9: Hospital water pipe

Because of the lack of a water source near the hospital, Nyaya has established large reservoirs at the hospital that are fed by a small pipe running over four kilometers away to the nearest reliable and clean water source. Given the distance the pipeline travels though, there are often breaks in the water supply, requiring Bayalpata staff to follow the pipeline backwards until they can find the leak and repair it. In the future, Nyaya hopes to develop a more permanent, underground system of piped water.

Photo 10: Bayalpata communications satellite

In order to maintain communication with local and regional authorities, and also with Nyaya’s extensive network of international volunteers, Nyaya has established a satellite internet connection, providing high-speed wireless internet in even the most remote of regions.

Photo 11: Bayalpata road following monsoon storm

Complicating Bayalpata’s operations even further, the transportation network in Achham is extremely poor. The roads are frequently washed out during monsoon season, isolating the hospital from its supply chain of pharmaceuticals, medical equipment, food, and other necessities, and preventing patients from getting to the hospital for care. The Nepali government is currently working to improve the quality of the road leading to the hospital, but the exact timeline remains unclear.

Photo 12: Nyaya Health Staff

In its mission to strengthen the Nepali public sector, Nyaya employs an all-Nepali staff, while partnering with volunteer clinical and public health experts from all over the world. Nyaya’s staff consists of 23 full-time personnel and is rapidly expanding. Nyaya’s Board of Directors, and all expatriate volunteers, are exclusively volunteer – Nyaya does not pay consultancy fees, and channels over 99% of its funds directly to health care services in Nepal.

Photo by Meredith Baker

[Editor's note: This is a guest post written by Meredith Baker. Her bio may be found at the end of the article.]

This past winter break, I had the opportunity as part of my undergraduate program to travel to Nicaragua and participate in community development work. While I have witnessed considerable poverty before, the community of Nuevo Amanecer, Nicaragua, brought me to a new understanding of what abject poverty can mean.

While the people of Nuevo Amanecer have a variety of basic needs, such as access to clean drinking water (they walk three miles a day to get water because local wells are contaminated), malnutrition amongst children is perhaps the most visibly dire. According to a UNICEF report, iron deficiency impairs the mental development of 40%–60% of children in developing countries. It can not only lead to anemia, but is also estimated to lower the GDP of developing nations by 2% due to lower energies and therefore low productivity of the workforce. Vitamin A deficiency leads to destroyed immune systems in children under the age of 5 and approximately 1 million deaths each year.

One hundred families live in Nuevo Amanecer (meaning “New Sunrise” in English), a community founded only a few years ago with the help of the Long Island student group “Students for 60,000.” The community serves as a permanent residence for “squatters,” or people who would have otherwise settled illegally or on public land. It was heartbreaking to see the kids of Nuevo Amanecer running around clothed only in dirty underwear – the only pair some of them owned. Most of the children were very skinny, with twig-like arms and legs, rotting teeth, and swollen bellies as a result of malnutrition and hunger. A few toddlers I encountered had thinning copper-colored hair (hypochromotrichia), a frequent symptom of protein deficiency.

The people of Nuevo Amanecer had a community vegetable garden. However, there were never enough fruits or vegetables to go around. The diet for most consisted predominantly of rice: good for carbohydrates, but lacking many other essential nutrients. This made me wonder if there weren’t an inexpensive, easy way to provide fortified foods to help these kids meet their daily dietary needs. Perhaps if the people of Nuevo Amanacer were educated on the necessary macro and micronutrients their bodies needed, and perhaps if aid organizations were able to provide fortified food or multivitamins in greater supply, the community’s emaciated children could at least begin to look and feel like healthy children their age.

Coincidently, my favorite columnist, Nicholas Kristof of The New York Times, was also in Central America at the time, writing a column about malnutrition in Honduras, with suggestions for simple, cheap ways to supply people in developing countries with necessary nutrients. In his article, Kristof reminds us that lack of vitamins and minerals and nutrients can have dire consequences and that it is cheaper and easier to prevent nutrition related birth defects than to treat them.

According to the UN Food and Agricultural Organization, the cost of fortifying food staples, such as sugar, salt, and flour with supplemental nutrients and vitamins can cost as little as 30 cents per person per year. One vitamin A capsule provides enough vitamin A for up to 6 months and costs around 2 cents. A three-month supply of iron pills is only 20 cents. This is a small price to pay for big returns.

Do you read our blog regularly, have good management/editing experience, a background related to health and human rights, and want to get more involved? The FXB Center for Health and Human Rights, located at the Harvard School of Public Health in Boston, seeks an intern to serve as OpenForum manager, available immediately. Must be able to work at least 25 hours per week during regular business hours. More information available here.

Liberia, a country whose identity is bound tightly to a history of unrest and violence, is attempting a new project in Montserrado County (the region that includes the capital city of Monrovia) in an attempt to confront the increasing problem of food insecurity. In an area where only 1% of residents grow their own food, the project’s promotion of “market gardens” has already made a difference for thousands.

Headed by the Food and Agriculture Organization (FAO) and funded by the Swedish International Development Cooperation, the new project is providing training sessions, agricultural education, and seeds to a fortunate 5,000 who own small portions of uncultivated land on the outskirts of Monrovia. The outcomes have so far been favorable. An individual, or more commonly a family enrolled in the program, can make around US$200 per season from red peppers (a fairly common crop in the area). For one young man participating, this meant a chance to go back to school. And the long term health benefits — not only to the individual but also to the community — that come from an increase in produce consumption are desperately needed: almost half of all children are affected by malnutrition.

The market gardens program, it is hoped, will encourage people in the areas surrounding a poverty stricken city to spread the once prevalent farming land back into communities. Seventy percent of the population in Montserrado once farmed their own land, but due to years of civil unrest, Liberia is currently utilizing a mere one third of the land available.

Food security is thus not a new problem, and although there are currently many valuable interventions in operation, the problem is reinforced daily by the overwhelming presence of slums within the region. Perhaps one of Liberia’s greatest challenges, the increase in slum population — now the greatest percentage in all of sub-Saharan Africa according to the UN–Habitat report — is inexorably linked to the country’s political climate and social dynamics. Liberia has been in civil war intermittently since 1980, when a military coup led by Samuel Doe ushered in a decade of authoritarian rule. Since then, relatively brief patches of peace alternated with unrest, with the situation settling down in 2005 with the democratic election of the current president, Ellen Johnson Sirleaf. The country is still reeling from years of instability and is attempting to recover from shifts in every area of society, most notably in a debilitating mass migration into Monrovia that has severely impacted food availability.

FAO’s current attempt to reinstate small farms is limited in its reach. For now, those included in the program are the relatively well-off that own land in the first place, and thus the entire slum population is counted out. The goal that the idea will “catch on” may be working, as it is laying a base for an increase in food production that could later benefit the entire region, including those living in slums. So far there have been positive outcomes not only for crop yield, but also for the personal goals and changed lives of the women and men involved.

For more info on the urban garden project: http://www.irinnews.org/report.aspx?ReportId=87798

For more general information on Liberia: https://www.cia.gov/library/publications/the-world-factbook/geos/li.html

For more info on food insecurity in sub-Saharan Africa: http://www.kahawacafe.com/pubs/ASR/12No1/Clover.pdf

For information on the housing crisis and prevalence of slums in Liberia: http://www.theperspective.org/articles/2007/0123200703.html

This evening [February 16] at 8:00 pm EST, Dr. Evan Lyon, Executive Editor of Health and Human Rights and member of the OpenForum blog team, will host a webcast to discuss his recent work in Port-au-Prince post-earthquake.

Click here shortly before 8:00 pm to participate.

More information on the webcast from Stand With Haiti, the Partners In Health blog covering their work in Haiti, including earthquake relief efforts:

Join PIH physician Dr. Evan Lyon for a presentation on his recent trip to Haiti and a live Q&A.

Tuesday, February 16, 8:00 pm EST

Dr. Evan Lyon has been a volunteer physician with Partners In Health/Zanmi Lasante for over a decade. He participated in PIH’s initial response to the earthquake on January 12, 2010 — just over one month ago. Since that time, the official death toll has reached 230,000 and continues to climb. At least 1.5 million are out of their homes — many have migrated back to the countryside. Those who remain in and around Port-au-Prince occupy makeshift refugee centers.

Dr. Lyon will speak about his two weeks at the University General Hospital (HUEH) in Port-au-Prince where PIH has helped coordinate efforts to bring this — the largest hospital in Haiti and its only public teaching hospital — back into a functional facility. After a brief presentation, he will answer your questions about the progress of Partners In Health so far, and the challenges that lie ahead.

We encourage students and teachers of all levels to join the discussion. To submit questions before the presentation, please email sdhr@dartmouth.edu. You may also submit questions during the presentation, via the live chat window found next to the livestream video. When submitting a question, please state your name and your school or location.

Please join us for this special presentation by visiting this webpage at 8:00 pm EST on Tuesday, February 16.

Suggested background reading:

“Haiti: A Creditor, not a Debtor” by Naomi Klein
http://www.thenation.com/doc/20100301/klein

“‘Break Hearts Open’ in Haiti” by Evan Lyon:
http://english.aljazeera.net/focus/haitiearthquake/2010/02/20102272125725938.html

“Fault Lines: The Politics of Rebuilding in Haiti”
Video: http://tinyurl.com/ydz7z7p

The information needs of frontline health care professionals are vast, ranging from the latest WHO protocols and country-level policies to knowledge of the newest life-saving technologies. Promising new technologies — including mobile health facilities; lightweight, portable diagnostic tools; solar-powered devices; and simple ways to save neonates — are emerging at a more rapid pace, but these developments are not centrally tracked. Such innovations are often reported in medical journals, but subscription requirements mean that this information is out of reach for many. In addition, most innovations are only written up once they are through testing and/or trials and not at the very early stages of their development. Thus, even after life-saving technologies are developed, a major barrier to use of these technologies still exists — knowledge of their existence. One solution: websites like Maternova.

Maternova is a new online knowledge-sharing platform (or “innovation portal”) that brings together social entrepreneurs who are developing or have developed life-saving technologies. The website allows all of their ideas and innovations to be documented in a single place. A number of these innovators are well known globally, but many of the innovations have only been uncovered after months of research. Now, innovators are starting to come to us through word of mouth.

As our name suggests, Maternova purposefully focuses on much-needed global access to information on maternal and newborn technologies. We also provide information on a variety of more general innovations — to us, anything that augments or expedites safe childbirth (for mother and infant) in the field is an innovation, including improvements in lighting, power, infrastructure, communication technologies, and, of course, health technologies. These are all part of a health system that can save mothers’ lives.

Three very basic questions guide our work. First, what are the effective, low-cost tools (both those in development and those on the market) that can save lives? Second, given the tools that exist, what are the priorities for new ideas? And third, where are the facilities located that can provide skilled care to women? Read more

Dr. Paul Farmer, PIH co-founder and the United Nations’ deputy special envoy to Haiti, shares his perspective on the Haitian earthquake disaster with PBS Newshour’s Ray Suarez during a televised interview. He discusses the challenges facing aid workers and the immediate and long-term needs of the Haitian community. Please watch the video below or visit the PIH website here.

A joint 2009 publication by UNICEF and WHO, Diarrhoea: Why children are still dying and what can be done, revives action-oriented discussion about diarrheal disease — one of the world’s direst threats to babies and infants living in unsanitary, under-resourced environments. The report provides current data on the distribution and burden of the disease and on how the most affected countries are working to reduce the toll of infant diarrhea. The report also includes a strategic seven-point plan for diarrhea control, describing prevention, intervention, and treatment practices that can and should be brought to scale.

Diarrhea is the second leading cause of death for children under five globally — with pneumonia being the first — and kills approximately 1.6 million children under five each year. Eighty percent of these entirely preventable deaths occur in the poorer regions of South Asia and Africa. Although major efforts in delivering treatments and effective prevention campaigns have reduced the global impact of infant diarrheal death, many low-resource communities still face barriers to accessing low-cost, life-saving remedies for their sick children. According to the World Health Organization (WHO), only 39% of children afflicted with diarrhea receive the recommended, inexpensive treatments of fluid replacement, zinc supplementation, and continued feeding.

Read more