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.

The diarrhea treatment plan outlined by UNICEF and WHO proposes two main solutions — fluid replacement and zinc supplementation — in addition to continued breastfeeding. The proven, standard treatment for fluid replacement is known as oral rehydration therapy (ORT), a solution of salts and sugars. WHO/UNICEF advocates for a reformulated version of ORT known as ORS, or low-osmolarity oral rehydration salts, which may be more effective overall in reducing the severity of diarrheal disease. Zinc also plays a vital role in decreasing the severity and duration of diarrhea, but how it works is still unclear. TIME calls zinc “the miracle mineral” in a December 2009 article profiling the profound affect that zinc has had on changing health outcomes and community perceptions about managing infant diarrhea.

WHO/UNICEF’s prevention strategy makes up the five remaining points of the seven-point plan, including “[1] rotavirus and measles vaccinations, [2] promotion of early and exclusive breastfeeding and vitamin A supplementation, [3] promotion of hand-washing with soap, [4] improved water supply quantity and quality, including treatment and safe storage of household water, and [5] community-wide sanitation promotion.” Nearly 90% of all diarrheal cases worldwide are attributable to unsanitary water and poor hygiene. Diarrhea is caused by a “wide range of pathogens, including viruses, bacteria, and protozoa.” While infrastructural changes may take a long time — and are much more out of an individual’s control — changes in behaviors and perceptions can go a long way in reducing susceptibility to these pathogens.

The impact of diarrhea is far-reaching and not yet under control. Only with concerted efforts that target both technical and behavioral improvements — water sanitation methods and hand-washing, for example — will the disease burden on developing countries begin to lift. If these improvements are made, communities and parents in the developing world, who were once resigned to the life-threatening illness, may begin to see how diarrheal disease can be managed and easily overcome. Parents can then begin to take control of their children’s health with relatively little cost and little effort.

A transcript of this segment can be found here.

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

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

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.

Victims of cluster munitions also need assistance with integration back into society. In many affected areas, people living with disabilities face stigmatization, marginalization, and a lack of economic opportunity. Efforts to promote the rights of the disabled — such as those spearheaded by Handicap International — are essential to any long-term approach to addressing the effects of cluster munitions.

Though cluster munitions are often compared to landmines in that they both litter areas after a conflict is over and pose a threat to the health and human rights of individuals and communities, there are notable differences in their effects. Cluster munitions are more likely than landmines to cause multiple injuries per incident, and they are more likely to kill or injure children under the age of 14 due to their small size and bright coloration.

Unexploded cluster submunitions slow humanitarian, recovery, and resettlement efforts after overt hostilities have ended. Humanitarian and relief workers may be unable to enter an area due to cluster munition contamination. In Kosovo, Laos, Vietnam, Afghanistan, and Lebanon, casualties peaked as populations returned home after the conflict ended. Returning populations are injured while attempting to access their houses, farms, pasture land, water supplies, and health facilities. In Afghanistan, many people have been injured by explosive remnants of war (of which cluster munitions are one form) in the past decade, and these deadly devices have deterred people from accessing health services and from sending their children to school.

The short- and long-term effects of armed conflict and political violence continue to undermine the health and human rights of populations around the world. An international ban on cluster munitions will be an important step toward protecting and promoting health and human rights and toward allowing those whose lives are ravaged by wars to farm their fields and walk the streets of their communities without fear.

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

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?

GHDonline.org — a platform where professionals from around the world engage in problem solving and share information resources to improve health outcomes in resource-limited settings — is one attempt to answer this question.

In June 2009, an infection control specialist from Swaziland posted on GHDonline.org’s TB Infection Control community asking for advice on how to design isolation rooms that maximize natural ventilation for multidrug-resistant TB patients. Within days, TB experts, architects, engineers, and other health care professionals from the US, the Netherlands, the UK, South Africa, and Italy — all members of the community — had responded with suggestions on room structure, software design programs, and literature references.

Instead of a one-way flow of information, this open platform facilitates a two-way flow wherein implementers on the ground access the most current and relevant information from peers and experts across the world, while at the same time sharing some of the issues they face in delivering health care.

As one architect describes, “We as architects are happy to listen in and get an insight on the subject matter and be able to relate with our area of expertise. Again thanks for your discussions we are able to understand the seriousness of the issues.”

Members can also discuss challenges and seek advice in their native languages, with several discussions having taken place in Spanish; for example, there has been a request for TB control guidelines in Colombia and a discussion about the 2009 Latin American Open Source Medical Informatics conference.

Additionally, following the HINARI model of partnering with publishers or “professional content makers,” resources like GHDonline.org can leverage partnerships to provide access to an increasing number of professional tools and content to its members at little or no cost. For example, a new international grant subscription program to UpToDate is now being offered on GHDonline.org to qualifying organizations and clinicians serving underserved communities.

While online tools such as GHDonline.org are important in sharing knowledge, electricity and internet access are prerequisites to accessing this information. Some off-line solutions have been developed for implementers in resource-limited settings, but these are makeshift options at best, as they do not address the need for up-to-date, context-relevant information. Furthermore, interactive exchanges, whether in person or online, allow for the advancement of knowledge and best practices in the field. In the context of providing access to life-saving health information, the provision of internet access is not a luxury, but a necessity.

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.

The bill also arrives on the heels of a widely condemned piece of pending legislation, the Anti-Homosexuality Bill, which “prohibits and penalizes homosexual behavior” in Uganda. The bill, proposed on October 14, 2009, contains a life imprisonment punishment for an “offence of homosexuality.” Punishment by death is recommended for those committing “aggravated homosexuality,” whereby the “offender”— or, a partner in a homosexual act — is HIV-positive, or the other partner is disabled or under 18 years old. Those charged would be forced to take an HIV test. The bill also carries penalties for individuals who know about gay persons but do not report them, striking a severe gash in the progress of HIV prevention and treatment efforts by alienating this high-risk group.

The bill will enter Parliament shortly and will most likely become law in early 2010. Its myriad egregious clauses, such as the death penalty, could be altered slightly, but their fates remain to be seen. The gross human rights violations that lurk in the bill — discrimination of vulnerable groups, roadblocks to treatment, privacy of HIV status — will no doubt be carried through to law in some capacity, and these violations bear a striking resemblance to those in the HIV/AIDS bill.

Despite its numerous critiques of the proposed HIV/AIDS law, the HRW report does not ignore some welcome attributes of the legislation, noting that several changes may “improve the potential for human rights protections.” For example, neglecting to inform one’s sexual partner of HIV status and failure to protect oneself from transmission is no longer criminalized, and children born to HIV-positive women will receive treatment and care. Still, the bill lacks a fundamental commitment to protecting the rights and the health of its citizens.

In early December, Elizabeth Mataka, the UN Special Envoy on AIDS in Africa, added her voice to those of the bill’s dissenters. “I emphasize the importance of creating a social environment conducive for HIV prevention and to refrain from laws that criminalize the transmission of HIV and stigmatize certain groups in the population,” she remarked in Kampala, Uganda, on December 2. “These laws can only fuel the epidemic further and undermine an effective response to HIV.”

Her lips to Parliament’s ears.

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.

But the public announcement of his policy overhaul stands to salvage his reputation and, of course, countless lives. South Africa has the highest prevalence of HIV in the world: UNAIDS/WHO estimate that 5.7 million are infected with HIV, including 3.2 million women and 280,000 children aged 0–14. Zuma’s particular focus on women and children heralds a concrete and strategic approach to curbing the spread of HIV/AIDS. He said that the policy changes to take effect next April would include treatment for all children under one year old who test positive for HIV, with no regard for their CD4 count. Treatment is expanding for other high-risk groups, such as people with tuberculosis and HIV, as well as pregnant women who are HIV positive. Counseling, testing, and treatment would all be part of the care package.

UNAIDS executive director Michel Sidibé spoke at the event before President Zuma took the stage. In his speech he correlated health and human rights, emphasizing in particular the position of women and children. He remarked, “AIDS reveals many fundamental injustices. While mother-to-child transmission is now part of the history books in the North, 390,000 African babies were born infected in 2008. Only half of pregnant women living with HIV in South Africa received treatment to prevent transmission of the virus to their child, even though evidence shows that with full access, we can virtually eliminate HIV infection in newborn babies.”

President Zuma hopes to cut infections in half and provide treatment to at least 80% of HIV/AIDS patients by 2011. It’s a tall order but not insurmountable, especially with aid from countries like the United States, which will give South Africa an additional $120 million over the next two years for AIDS treatments. Zuma’s policy reforms are a milestone in South Africa’s battle with HIV/AIDS, but his ultimate success lies in their translation into practice and implementation. Only then can a more ambitious goal be sought: universal access to treatment.

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.

Additionally, Easterly fails to explain why global health assistance forms a rational basis for predicting how a rights-based approach would operate in the US context. First, domestic and foreign health allocations are driven by different political and public health considerations. Americans carry a larger chronic disease burden, while low-income countries, generally the target of global health funding, carry a larger infectious disease burden. For example, communicable diseases account for just 8% of years of life lost in the US but account for 68% of years of life lost in developing countries. By contrast, noncommunicable diseases account for 74% of years of life lost in the US but just 21% in developing countries (see the WHO 2009 World Health Statistics). Additionally, there are different delivery and funding mechanisms at work in each context. A recent survey of 12 African countries showed that there are 9 physicians per 100,000 people, whereas there are 270 physicians per 100,000 people in the US. Second, it is unclear how the right to health would result in both more spending and worse outcomes than the status quo. On the one hand, Easterly argues that it would lead to fierce competition for resources. On the other hand, he argues that it would result in reckless spending. The US health system is already characterized by overspending and overtreatment for tertiary levels of care (also see the Dartmouth Atlas Study), coupled with disparities in access and outcomes for the medically underserved. In fact, emphasizing universal access to primary care would result in saved costs and improved outcomes.

Finally, Easterly makes flawed assumptions about the historical drivers of global health assistance. First, his criticisms are misdirected, as the very policies and programs he decries were never based on the right to health. Instead, they reflect political decisions to fund targeted, vertical interventions over horizontal investment in the public sector. Second, his opposition to a rights-based framework is short-sighted since this siloed approach does not go far enough in promoting health. The WHO definition of health extends beyond mere absence of disease to “complete physical, mental and social well-being.” Yet the foreign aid “successes” Easterly cites, such as immunizations and antibiotics, were only aimed at preventing death. Because they do not address fundamental causes, they are incapable of preventing disease. It is ironic, then, that Easterly tries to support his complaints about global health funding by holding up the most vertical and least effective models of “global health care.” If good is measured by “obtaining the largest possible health benefits,” only a rights-based approach ensures these benefits go deep enough and broad enough to meet the needs of the poor.