Photo by Laurie Wen

Monday, March 8 marked the celebration of International Women’s Day, a global tribute to the economic, political and social achievements of women past, present and future. In this guest post, Dr. Agnès Binagwaho, Permanent Secretary of Rwanda’s Ministry of Health, reflects on the human rights of women in Rwanda.

Sixteen years ago, during the 1994 Rwandan Genocide, perpetrated by Hutu extremists against Tutsis and the Hutu moderates, where one million people were killed — more than one tenth of the Rwandan population — women’s rights were profoundly denied, as many of our mothers, sisters, and girls endured systematic massive rape that resulted, often intentionally, in the devastating effects of a slow death by HIV/AIDS infection. During that time the country was destroyed, its health system ceasing to function as health professionals were killed or left the country and infrastructure and materials were destroyed. As this week we celebrated International Women’s Day 2010, I salute the fact that rape as a weapon of war has been recognized as a crime against humanity.

Times have changed in Rwanda. Thanks to the new leadership since 1994, most of the population thinks “out of the box,” with a strong belief that there is always a solution if we work hard to find it and if we search for solutions within our culture and within ourselves. In this short essay, I would like to share how the situation during the time of the genocide has been reversed to favor women rights and how it impacts my work.

Click here to continue reading Agnès Binagwaho’s piece, “What do human rights mean for a working woman in the Rwandan health sector? Reflections on International Women’s Day.”

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?

Certainly Haiti is in desperate need. Yet the discrepancy between the aid provided before 16:23 on Tuesday, January 12, 2010, and the outpouring of funds since then is hardly consistent with the constancy of need that Haiti has expressed for decades. Will Haiti remain a point of awareness for those who feel this recent increase in responsibility, or will it disappear back into the realm of public health experts and anthropology lectures at elite universities as it has so often before?

If a similar event struck even one American city — a hypothetical transformation in 12 hours, in which time all basic health indicators, poverty levels, and living conditions become identical to a portion of the population on the outskirts of Port-au-Prince in 2008 — gross national income per capita would drop US$43,000. Infant mortality would jump 857%. Three percent more people would have AIDS, and TB rates would increase by 1,344 %. Unimaginable? Yet even these changes would fail to convey the years that Haiti has lived as one of the most impoverished nations of the world. A history of discord and poverty has combined to create an unshakable stigma that shrouds any association with the country. With this comes outside prejudice, and from prejudice the extensive debilitating components of social suffering. An earthquake with a magnitude of 7.0 hitting the country’s capital city is only the tip of the iceberg. Haiti needs the world to extend a hand not only in the coming months, but the coming decades.

Psychological factors make it so easy for us to forget, and sometimes hard to empathize with, suffering. Perhaps by acknowledging our psychological default setting we can improve everyday awareness of global suffering and increase long term action.

There are two primary limitations to comprehending the suffering of others. The first is internal: we are naturally programmed to feel more sympathy towards individuals than groups. Several studies have been done tracking gross donation quantities based on the picture that accompanied a campaign. Those pictures with a single child staring with longing into the camera resulted in considerably more money than the simple addition of one more child to the picture. Human empathy is simply not hardwired to deal with numbers and vast areas of suffering. A death count of 105 seems not much different from 103, yet when a report states that two were dead, we care. Indeed it appears that the fewer the number, the easier it is for onlookers to develop collective empathy. The second limitation is that of language: there are many instances when a limited vocabulary cannot convey the intense emotion that accompanies a tragedy; and increasingly in the medical world, there is an absence of jargon to fully explain the subtleties of suffering. Reading of one’s suffering, in short, can limit our ability to fully comprehend its depths.

Of course, some possess a greater ability to empathize than others, and empathy measures are inevitably generalizations. But taking human nature into account and applying it to a sustainable support strategy could perhaps keep Haiti on the radar. As the world marches on in the coming months and years, it is important that we not only remember Haiti, but also that we actively fight against the natural processes that makes us forget.

For more opinion on this subject see: http://www.nytimes.com/2010/01/14/opinion/14thu1.html

http://www.washingtonpost.com/wp-dyn/content/article/2010/02/01/AR2010020103183.html

http://www.nytimes.com/2009/07/09/opinion/09kristof.html?_r=2

For the empathy study cited see: http://pluto.mscc.huji.ac.il/~msiritov/KogutRitovIdentified.pdf

For up to date info on Haiti see:
http://topics.nytimes.com/top/news/international/countriesandterritories/haiti/index.html?scp=3&sq=haiti%20death%20toll&st=cse

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.

The district of Achham in Nepal suffers from some of the highest rates of poverty and maternal mortality in all of South Asia. Before Nyaya Health opened its first clinic, there was not a single allopathic doctor in the area; perhaps not surprisingly, 1 out of every 125 deliveries results in the mother’s death, with less than 0.5% of deliveries occurring in a health facility. Achham’s remoteness also means that, in a country that boasts one of the world’s most famous trekking and tourism industries, 95% of the households are without electricity and only 45% of people have access to safe drinking water.

In 2008, following a civil war, Nyaya Health opened the first primary health center in the region. Shortly after opening the clinic, the community requested that Nyaya take over administration of Bayalpata Hospital.

Bayalpata Hospital, built in 1976, was designed to be the first hospital in the Achham district of rural western Nepal. In a bureaucratic entanglement of political conflicts, the funding and equipment for the hospital were sent to a more powerful constituency in the district. The people of Achham came together as a community, protesting this injustice; the military opened fire on them as they surrounded the facility, killing several and wounding and imprisoning many more. The hospital remained empty, its walls rotting and decaying with time.

In an effort to bolster the public sector health system, Nyaya partnered with the Nepali Ministry of Health and Population (MOHP) to begin rebuilding.

As Nyaya began to rebuild the dilapidated hospital, broad, system-level infrastructure development was a clear priority. Having sat dormant for over 20 years, Bayalpata Hospital was a shell of a health care facility. With crumbling walls, not a single piece of medical equipment, only a scant few chairs and cabinets, faulty electricity and running water, and staff quarters that were too damaged to be repaired, the hospital required extensive renovation. Complicating this process was the fact that the dirt road leading to the hospital was of incredibly poor quality and often impassable, making transportation of supplies extremely difficult.

In 2009, Nyaya re-opened Bayalpata Hospital. Striving to empower the Nepali public sector, Nyaya prioritized the hiring of an all-Nepali staff. This however, in an area as remote and impoverished as Achham, proved challenging as well: brain drain, both internal (to metropolitan areas such as Kathmandu) and external (to the USA and Europe), pulls the most well-trained from the region, leading to a dearth of qualified personnel. Nevertheless, Nyaya continually works to hire locally, thereby improving the area’s own capacity and development.

Upon opening the hospital in June, 2009, Nyaya had restored two clinical buildings, a staff kitchen, and two of the staff quarters. In addition to outpatient and maternal health services, Bayalpata Hospital became home to the first emergency room in the region, as well as the first inpatient ward. While radiological services were initially limited to ultrasound, an X-ray facility is currently being built, and plans to scale-up comprehensive surgical services are being developed. All services are offered completely free of charge, 24 hours a day, 7 days a week.

Nyaya believes fundamentally in health care as a human right, and accordingly, is working toward the development of not only a hospital, but an entire community-based health system. While still nascent in its work, Nyaya aims to expand its community programs over time, recognizing that only wide-ranging infrastructure development will affect population-level health change. By working toward a goal of full accountability and integration with the public sector in particular, Nyaya aims to walk in solidarity with both the people of Achham and with the local and national governments, strengthening Nepali capacity broadly while prioritizing the most marginalized populations and ensuring health equity for all.

For more information on Nyaya Health, please visit http://www.nyayahealth.org and http://blog.nyayahealth.org.

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.

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

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?

An example of a simple, low-cost, life-saving tool is a calibrated bag that is used to measure postpartum hemorrhaging, which is the leading cause of maternal death in low-resource settings. In these settings, there is often no way to measure how much blood a woman is losing during delivery — often midwives will simply look at how many cloths are soaked through with blood. A group in India developed a calibrated drape — a bag that simply collects the blood and measures volume of blood lost. This simple plastic bag can (with proper training of the birth attendant) help signal when a woman needs to be urgently referred to a higher level of care.

Mahmoud Fatallah eloquently stated a connection between maternal survival and human rights, saying “When women are risking death to give life, they are entitled to have their own right to life and health protected.” The rights to skilled care at birth, to measurement of what is going wrong in labor and delivery, to other life saving tools are all extremely concrete dimensions of the human right to health.

Our approach is extremely practical, and we rely upon reports from the field about new, simple technologies and about which techniques that are working. For example, through the Maternova site, we learned that a group in California has imported the drape concept from India and is now using it throughout the state.

We believe that by connecting the various groups already linking nurses, midwives, and physicians (including GHDonline’s Global Health Nursing and Midwifery Group) and exchanging concrete solutions, we can accelerate and amplify the kinds of exchanges described in the calibrated postpartum hemorrhage bag example. And looking forward, we would like to assist these groups in bringing their own priorities for innovation to the forefront of global health policy dialogue.

For more information, please visit http://maternova.net. To go directly to the tools for maternal health, please see http://maternova.net/tools/to-save-mothers, and for the tools for newborn health, please see http://maternova.net/tools/to-save-infants. For Structures and Systems, please see http://maternova.net/tools/structures-and-systems. And if you have a specific idea for an innovation to be featured in the Index, please send word through the comment section on the Maternova site.

Meg Wirth is the founder of Maternova and a S.E.VEN fellow. She has worked on women’s health and inequalities in health throughout her career in Appalachia, for John Snow International’s Mothercare project in Jakarta and South Kalimantan, Indonesia, and for the Rockefeller Foundation. She is also a co-author of the UN Millennium Project’s final report on child and maternal health titled Who’s Got the Power? She has a BA from Harvard University and an MPA in international development from Princeton University’s Woodrow Wilson School.