OpenForum – a blog by the Health and Human Rights community

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.

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Amy Goodman of Democracy Now! reported on the situation in Haiti yesterday. She spoke extensively with Dr. Evan Lyon at the general hospital campus in Port-au-Prince about the lack of supplies and the misconceptions about security in Haiti.

A transcript of this segment can be found here.

Dr. Lyon was also interviewed yesterday on Here and Now.

Haiti was shaken yet again Wednesday, January 20, by a 5.9-magnitude aftershock that lasted approximately 7 seconds, cutting no break for the hundreds of thousands of already-devastated Haitians and the aid workers there to help them. There have been more than 40 aftershocks since the shattering quake on January 12. This latest shock, certainly the largest, centered about 35 miles northwest of Port-au-Prince and about 6 miles below the surface, according to the US Geological Survey.

Meanwhile, rescue operations continue at full speed — medical personnel, military forces, and other aid workers and peacekeepers have arrived in droves in Haiti over the past week. There has been bottleneck at the airport in terms of receiving and distributing goods, due mainly to capacity, security, and communications issues. The provision of surgical services, food, water, shelter, and medical supplies has been mobilized as quickly as possible; nothing seems efficient enough, though, considering the sheer size and immediacy of the demand.

Dr. Evan Lyon, a Partners In Health clinician currently in Haiti, executive editor of Health and Human Rights: An International Journal, and co-founder of the OpenForum blog, shares his experiences on the ground in Haiti. His communications have been published on the Partners In Health website, and we share his latest update below.

Click here to read more of Dr. Lyon’s experience in Haiti.

Click here to hear the January 16 “Radio Rounds” interview with Dr. Lyon.

[Editor’s Note: The following note from Dr. Lyon is reposted from the Partners In Health website.]

01/19/2010

Dr. Evan Lyon has been on the ground working at the general hospital in Port-au-Prince since Saturday [January 16]. He’s working with a partnership between PIH and the Haitian Ministry of Health to coordinate restoring services at the hospital.

For many years, PIH’s sister organization Zanmi Lasante (“Partners In Health” in Haitian Creole) has been one of the largest and most attractive training sites for graduating medical students. The majority of our doctors and nurses, pharmacists, and lab technicians, have trained at the general hospital in Port-au-Prince, Hôpital de l’Université d’état d’Haiti (HUEH). Until less than a decade ago, all doctors trained in Haiti graduated from the national medical school and received training at the general hospital. Zanmi Lasante has been honored to host many of the top graduates of the national university in their first year out of medical training for a year of social service. Zanmi Lasante’s finest medical staff are among these graduates, who are now leading Partners in Health’s efforts to respond to the disaster.

The general hospital sustained massive damage; at least 50 percent of the campus cannot be used. Many buildings are destroyed. All are cracked. Only some are safe to work in. The adjacent nursing school was completely destroyed–we are working in its in the dusty shadow, where the bodies of many, many second year nursing students remain trapped in the rubble. It will be weeks or months until the rubble is cleared. The smell of death is everywhere. Many of the dead are our sisters and brothers in health, who had worked alongside us to relieve suffering.

Today we worked to get the university hospital on its feet again.  Dr. Lassegue, the hospital’s director, and his staff are leading efforts to care for the injured.  Partners In Health is working closely with the hospital to provide care and to help organize relief efforts from international aid agencies from around the world.  Surgeons had been operating with daylight and flashlights but electricity is now restored. Seven operating rooms are now performing surgeries.  An estimated 1000 patients have already been assessed and are awaiting surgery on the campus. People are lying on mats on the ground, in shade where it can be found, under sheets strung from the trees.

Inpatient wards are coming together. We hope to increase to ten operating rooms in the next 48 hours, with 24-hour service now that the electricity has been restored. The hospital must stand again.

As I left the hospital compound this evening, I saw the lights of a large front-end loader working near the morgue. Three dump trucks were at the ready. Where thousands upon thousands of bodies had lain just days ago, only 40-50 bodies remained. Swollen, alone, pushed to the side of the pavement slippery with blood and body fluids.

As I walked past the morgue and the largest pile of bodies, I noticed that one was wearing a Zanmi Lasante t-shirt. I cannot begin to understand why this small detail made a scene of unspeakable sadness even sadder.

- Evan Lyon

[Editor's note: This is a guest post written by Sujal Parikh.]

On December 22, New Zealand and Belgium became the 25^th and 26^th nations to ratify the Convention on Cluster Munitions (CCM). The convention needs only four more ratifications to achieve the 30-state minimum to enter into force. Once in force, it will enact a ban on the use, stockpiling, production, and transfer of most cluster munitions, which include bombs, missiles, or rockets that open midair to scatter tens to thousands of small submunitions over a wide area. The CCM also requires that states destroy their stockpiles in eight years, clear contaminated land within ten years, and provide victim assistance.

This convention is necessary due to the wide, indiscriminate, and persistent effects of cluster munitions on civilians and communities. Ninety-eight percent of all recorded casualties of cluster munitions are civilians. In several countries, children account for roughly 60% percent of the victims. In 2007 alone, 5,426 casualties were reported due to cluster munitions. Conservative estimates suggest that unexploded submunitions have caused at least 55,000 casualties, though the number may be well over 100,000.

Victims of cluster munitions require medical, mental health, rehabilitation, and vocational services. They sustain burns and blast and shrapnel injuries, often to multiple limbs as well as their chest, abdomen, and face. Victims should also receive rehabilitation services, including mental health care, physical therapy, and prostheses if needed. Many of these services are unavailable or scarce in conflict zones, and the added burden of these patients can overwhelm an already strained health system, especially in post-conflict settings.
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A major earthquake of 7.0 magnitude hit Haiti yesterday just ten miles outside of Port-au-Prince, the nation’s capital. The quake centered on one of the most densely populated areas of one of the poorest countries in the Western Hemisphere, knocking out telephone communications, causing the collapse of buildings and homes, and potentially killing thousands of people and injuring tens of thousands more. The extent of the devastation is still unknown, but the country is in urgent need of immediate support to provide food, water, medical supplies, and shelter to countless victims. Longer-term recovery and rebuilding aid is also in imminent need.

A number of international aid efforts have already been mobilized. The US government, the US Coast Guard, the US Agency for International Development (USAID), and Haitian communities in the US have organized a range of support efforts. International aid agencies such as Oxfam, the International Red Cross, the British Red Cross, and Médecins Sans Frontières, among other agencies, have also announced their emergency assistance support. Haiti has recently been able to operationalize its airport to receive resources.

Boston-based Partners in Health has worked on health and development in Haiti for over two decades, and the organization has set up an emergency field hospital and has sent out various communications about the tumultuous event. Executive Director Ophelia Dahl writes, “In an urgent email from Port-au-Prince, Louise Ivers, our clinical director in Haiti, appealed for assistance from her colleagues in the Central Plateau: ‘Port-au-Prince is devastated, lot of deaths. SOS. SOS… Temporary field hospital by us at UNDP needs supplies, pain meds, bandages. Please help us.’” You can help Partners in Health and earthquake victims by making a contribution, as explained on the PIH website.

The US State Department has set up the following number for US citizens seeking information about family members in Haiti: 1-888-407-4747.

For the latest developments in Haiti, see the following news and information web links:

PIH Updates

US Department of State

ReliefWeb

BBC News

CNN International

Al Jazeera’s The Americas Blog

USA Today

Oxfam

In India, a woman enters a village health center and accesses a web page for information on how to better care for her baby. In Boston, a doctor at the Brigham and Women’s Hospital (BWH), one of the world’s most elite hospitals, pulls up the UpToDate website — an online medical information resource used by many clinicians to stay current with the latest clinical advances and practices — for information to help diagnose and treat a patient.

The World Wide Web has connected health care implementers with a vast sea of knowledge and experience. From mothers to doctors to architects to IT technicians to government policy makers, each of these actors faces daily challenges on how to deliver quality health care. Some are sitting in first-class hospitals in developed countries, while others are in isolated rural clinics in the poorest countries. Some are new to their role, while others have been in the field for as long as they can remember.

Unfortunately, many health care implementers are unable to access the information they need on the internet. Most online journals and medical information resources charge subscription service fees. Recognizing this financial barrier, there has been a strong drive to make access to scientific journals free for health care implementers in developing countries.

In 2002, the World Health Organization launched HINARI, a program to provide access to major scientific journals for public and non-profit institutions in developing countries. Other initiatives include the Global Information Full Text database and the Open Access movement by which some publishers, such as Biomed Central and PloS, make articles freely available on the internet.

However, there is no guarantee that the breadth of health implementers practicing in resource-limited settings are able to understand and utilize this new set of information — especially scholarly papers or resources not applicable to their point of care. Language barriers, computer and internet literacy issues, and information overload are a few other challenges that they face. The woman in the village may not necessarily be able to use the information she finds on the internet to improve her child’s health as “trying to get information from the Internet is like drinking from a fire hose.”

So how do health implementers access the most reliable, practical, and current information that is most applicable to their particular situation?
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Ugandan legislators recently released the latest version of a controversial HIV/AIDS bill that “promotes dangerous and discredited approaches to the AIDS epidemic,” according to Human Rights Watch (HRW). In a response report published by HRW and endorsed by more than 50 organizations and individuals, HRW criticizes Uganda’s proposed HIV Prevention and Control Bill for the repressive nature of several new clauses while pointing out some of its more agreeable aspects.

As written, the draft law threatens human rights and progress toward universal access to treatment. The most alarming changes include the criminalization of intentional transmission of HIV, which could result in life imprisonment; compulsory testing of drug users, pregnant women, sex workers, and victims and charged offenders of sexual violence; and forced disclosure of HIV status. The government’s role in providing access to affordable treatment has been removed from the legislation.

“We know what works and what doesn’t in fighting HIV,” said Beatrice Were of the Uganda Network on Law, Ethics & HIV/AIDS. “This bill, unfortunately, is full of ineffective approaches that violate human rights and will set us back in our efforts to fight the AIDS epidemic and expand HIV programs nationwide.”

The bill’s most troubling traits are particularly unjust to women and high-risk groups. Because women are tested for HIV during pregnancy, a disproportionate number of women will know their HIV status and will thus be prosecuted disproportionately. The bill does not consider and protect a women’s inability to negotiate condom use or to tell a partner about her status — a partner who may have transmitted the disease to her in the first place. The HRW analysis finds that women who transmit HIV to their infants by feeding them breast milk would face criminal prosecution. Although the legislation exempts mother-to-child transmission “before or during the birth of the child,” the law does not protect mothers after child birth — the period of time when breastfeeding occurs. Additionally, there is little mention of counseling or support services for minors.

In short, the bill fails to provide a legal framework favorable to the effective national management of the epidemic. It fails to chip away at the more elusive yet fundamental perpetuators of the disease: stigma and discrimination.

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During his speech on World AIDS Day, South African President Jacob Zuma promised to ramp up HIV/AIDS prevention and treatment programs for children and high-risk groups. The new plan calls for treating all HIV-infected babies in a country whose child mortality rate has risen since 1990. “Our message is simple,” President Zuma said, “we have to stop the spread of HIV. We must reduce the rate of new infections. Prevention is our most powerful weapon against the epidemic.”

President Zuma’s commitments set a new ideological standard in South Africa that breaks from previous conceptions of the disease. Former President Thabo Mbeki received widespread criticism for his ideas about the nature and treatment of the epidemic. He is often noted as a denialist of the viral cause of AIDS and the effectiveness of antiretroviral treatment. A Harvard University study reported in The New York Times found that more than 330,000 premature deaths could have been prevented if Mbeki’s administration had backed the provision of antiretroviral drugs to AIDS patients.

Despite Mbeki’s misguided stance, that Jacob Zuma reversed his predecessor’s rhetoric on HIV/AIDS came as somewhat of a surprise. A husband to three wives – an acceptable facet of his Zulu heritage but a risk factor for contracting HIV – and the defendant in a 2006 criminal case for the rape of an HIV-positive friend, he is an improbable leader in the AIDS movement.

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[Editor's note: This is a guest post written by Sarah Mi Ra Dougherty.]

In a recent opinion piece in the Financial Times, William Easterly argued that a rights-based approach to health care would favor the agendas of the rich and powerful, leaving the poor to die of neglected diseases. He then contends that holding ourselves to such unrealistically high standards would open the floodgates for unchecked spending, “since any of us could get healthier with more care.” Unfortunately, both of his slippery slope arguments are premised on inaccurate assumptions about the right to health, health spending dynamics in the US, and the history of global health assistance. The inequalities he describes are not the result of a push to promote health as a universal good. Instead, they are the flawed legacy of institutions and policies that persist in treating health as a commodity.

At a basic level, Easterly distorts the purpose and scope of a rights-based approach to health, specifically what is meant by “highest attainable standard of health.” He frames this as a personal right to absolute health, subject to immediate realization, when it is actually a collective right to equivalent health, subject to progressive realization (ICESCR, Art. 12). This mischaracterization underlies Easterly’s argument that human rights operate in a zero-sum environment. In reality, the right to health goes beyond mere delivery of goods and services; it is fundamentally concerned with promoting equitable outcomes and empowering people to achieve these ends. The problem is not one of scarcity: rich countries contribute less than 1% of their gross national income to support health care in poor countries. Rather, it is one of exclusion: the current balance of rights and duties fails to contemplate that everyone is entitled to a basic level of health. The Millennium Development Goals seem so ambitious because they seek to extend to all what those of us in the developed world take for granted — “minimum essential levels” of health and the preconditions for health, such as access to water, sanitation, and nutrition. While a certain amount of jockeying for priority is to be expected, it would take place within this basic inclusive framework. By resorting to economic scare tactics, Easterly displays fundamental misunderstanding of what is at stake in the human rights debate.

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