Beyond issues of consent and individual choice, early marriage poses grave health threats for young girls. Not yet physically mature, they face grave danger in childbirth, due to narrow pelvises. Girls younger than 15 years of age have a five times greater risk of dying during delivery than women over 20;  most of these deaths occur  in developing countries that lack adequate and accessible pre- and postnatal care.

“What you often see is that a girl gets married and within a month she becomes pregnant. That’s where the problems start because your body is not ready… Their reproductive organs aren’t mature enough,” says Fatou Diakhate, a Senegalese woman who was married at 13 and went on to fight to ban child marriage in her village of Keur Issa in 1998.

The heightened risk of obstructed or prolonged labor can lead to obstetric fistula, a  stigmatized condition that can be prevented by cesarean section, but only in settings equipped to provide such a procedure. These young brides are also at greater risk for STDs and HIV/AIDS, as they are frequently married to older men who have had more sexual partners.

Child brides share health threats with their children: babies born to mothers younger than 18 are 60 percent more likely to die before their first birthday than those with mothers more than 19 years of age. Driven by pervasive poverty in the developing world, child marriage is a deep-rooted cycle with urgent and lasting health consequences.

Photo courtesy of FXB Center for Health and Human Rights at the Harvard School of Public Health

Women face particular danger of sexual assault and violence when searching for firewood in the bush outside of the camps. With many refugees in competition for wood, tensions are high. Boisson quotes  Sinead Murray of the International Rescue Committee as saying, “There’s a fear of going to the bush because they think they are going to encounter violence. Many women say that there are men in the bush and these men have guns and they’re going to attack.”

Even the numbers of reported attacks in Dadaab are misleading; the stigma associated with sexual assault, coupled with lack of confidence that perpetrators will be penalized, leads to an underreporting of gender-based violence. While aid groups work to offer counseling to victims and provide female refugees with whistles and flashlights, the pervasive threat of violence against women in the camps reveals the complete lack of protection and security of the displaced Somalis.

Voice of America also reports on sexual violence against Somali women.

Photo by Oxfam East Africa [CC-BY-2.0 (www.creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

A recent study published in The Lancet underscores these health inequities suffered by children in sub-Saharan Africa. The report, “Bacteraemia in Kenyan children with sickle-cell anaemia: A retrospective cohort and case-control study,” examines retrospectively the prevalence, diagnosis, and treatment of bacterial illnesses associated with sickle-cell anemia in Kenya.

At the Kilifi District Hospital in Kenya, the researchers collected and studied blood cultures from approximately 38,000 children under 14 years of age who were admitted between August 1, 1998, and March 31, 2008. They identified approximately 2,000 cases of bacterial infection. Sickle-cell anemia was identified in over 100 of these cases, but three-quarters of these children did not receive this diagnosis until admission for a bacterial infection.

Although studies show that antibacterial prophylaxis and vaccination can improve the prognosis for people born with sickle-cell anemia in developed countries, few guidelines exist in Africa that would improve the detection and treatment of the disease and its related infections. According to the researchers, “few studies have described the bacteriology of sickle-cell anaemia in sub-Saharan Africa despite the fact that more than 200,000 African children are born with this disease every year.” The dearth of data, most likely due to underreporting, contributes to the stalled development of evidence-based guidelines that could save thousands of lives.

Vaccines against Streptococcus pneumoniae and Haemophilus influenzae, the most common causes of infection among children with sickle-cell anemia, are administered regularly in developed countries. The uptake of such preventative measures has been slow in Africa due to funding priorities for other pervasive diseases such as HIV and malaria. A Reuters article about the study mentions that the Global Alliance for Vaccines and Immunization (GAVI) currently provides an effective vaccine for Haemophilus influenzae type b (Hib) to 35 African nations and hopes to roll out an improved pneumococcal vaccine across Africa in the next few years.

The Lancet study results suggest that “bacterial infections are a major cause of morbidity and mortality in children with sickle-cell anaemia.” Unless greater attention is given to identifying and treating the disease in developing countries, sickle-cell anemia will continue to contribute to child mortality. Targeted interventions would save lives and lead one step closer to reaching the Millennium Development Goal of reducing mortality in children younger than 5 years old.

At a recent conference, health delegates from 42 countries agreed to implement a new strategy that trains NPCs in emergency obstetric surgery to address the lack of health care workers. Along with other developing areas, most African countries are suffering from a significant lack of medical professionals. This shortage is particularly implicated in the high rates of maternal and infant deaths during childbirth. The WHO has estimated that in sub-Saharan Africa alone, there is a shortage of nearly 1.5 million health care workers; women there face a 1-in-13 risk of dying in childbirth. Most women are unable or unwilling to access medical facilities or workers, even during emergencies; for example, in Ethiopia, only 6% of all births occurred in a health facility.

By expanding the number of NPCs and training them in surgical childbirth procedures, it is hoped that more births will be attended by trained health care workers who can assist women during emergencies. A program in Mozambique that trains midwives in surgical techniques has already achieved significant results. The country is on the way toward meeting several of the UN’s Millennium Development Goals, particularly those surrounding maternal and newborn health.

In a similar low-tech program, USAID’s maternal health group ACCESS (Access to Clinical and Community Maternal, Neonatal, and Women’s Health Services) focuses on developing and extending home and community based interventions. A new report from ACCESS is a guide for carrying out “community mobilizations” to improve maternal and newborn health. The program focuses on identifying the specific obstacles of the community, and working with the population to implement realistic changes. For example, essential interventions like the use of misoprostol (which induces labor) can generally be provided safely by trained health care workers at the household and community level, and prevent almost 70% of infant deaths. Additionally, simple preparations, such as providing folic acid to the mother during pregnancy and preparing a clean space for the birth, can be done by community health workers trained in pregnancy and childbirth.

More information:

Video: Birth of a Surgeon (documentary of Mozambique’s midwife training program)

In War and Isolation, a Fighter for Afghan Women

Bold Solutions to Africa’s Health Worker Shortage

Malawi: Role of traditional birth attendants to change

Global Low-cost Health Initiatives

A June article in the New Yorker by Atul Gawande, which is reportedly required reading at the White House, examines the costs of health care by looking at the most and least expensive health-care markets in the US. In particular he studies McAllen, Texas, which has one of the highest costs of medical care per person in the country, and Rochester, Minnesota (home of the Mayo Clinic), which has among the lowest. Rochester also provides some of the best quality health care in the nation. Gawande’s findings led him to conclude that the Mayo Clinic system, which pays doctors an annual salary to keep them from treating their practices like “profit centers”, and emphasizes a peer-review process to improve quality of care, are the best hope for improving American health care. This requires breaking the “untenably fragmented, quantity-driven” systems that are becoming the norm in US medical care.

Gawande notes at the end of his piece that the decisions that need to be made about America’s health care system are greater than the public versus private insurance debate; rather, they involve a total reorganization of the health system. Enacting the principles already in place in the lowest-cost, highest-quality medical institutions in the country – removing any financial incentive for doctors to order unnecessary procedures and taking collective responsibility for patients – require a significant reordering of our priorities.

Others are also looking outside of the political discussions that focus on either “raising taxes or cutting care,” instead seeing a better way: “redesign.” Medical professionals from ten communities across the country with below average health spending and above average health outcomes recently traveled to Washington DC to discuss how changes they have implemented have lowered cost without reducing quality. Gawande, one of the meeting’s organizers, explained that change in these communities occurred quickly, as “[h]alf of these communities used to be high cost and transitioned to low cost over the last decade,” suggesting that national reform is also possible.

The meeting, organized by the Institute for Healthcare Improvement, allowed professionals from low-cost, high-quality hospital groups to exchange ideas about cutting costs and preventing unnecessary care. For example, physician groups in Everett, Washington were combined and two hospitals were merged while health coaches counseled healthcare workers to smooth admission and discharge practices. A health group in La Crosse, Wisconsin, has focused on working with elderly patients to create advanced directives, a crucial component of end-of-life care that can also help lower healthcare costs significantly. These methods, along with a shift to electronic medical records, improvement in health care data collection and better coordination among providers, were among the most common steps cited by medical groups seeking to restrain expenses.

Similarly, health care practitioners in Birmingham, Alabama studied a health program in Zambia to create their own AIDS clinic based on the Zambian model. At this clinic, called “Project Connect,” patients receive appointments in five days or less after calling, and social workers interview all patients to address issues that might make it difficult for a patient to return for follow up appointments. Another example is the Prevention and Access to Care and Treatment Program, a community-based project that uses community health workers to assist HIV/AIDS patients in staying adherent to treatment. The program, modeled on work begun in Haiti under Partners in Health, has been adopted for use in inner-city Boston and is expanding to include New York City and Miami.

Mark Dybul, the former US Global AIDS Coordinator, explains why methods of care in poorer nations are now receiving greater attention: “We learned from Africa that in a very resource-limited setting, you can do very effective chronic care delivery that doesn’t have to be overmedicalized.” With much of the debate on health care reform focusing on lowering expense, it appears that these cost-effective programs from the developing world will become more popular to US health care providers.

More information on health in America:

Getting good value in health care

Whistleblower tells of America’s hidden nightmare for its sick poor

Concerns on plan show clashing goals

Forget who pays medical bills, it’s who sets the costs

Community health worker administering medicine in Rwinkwavu. Photo courtesy of Partners in Health.

[Editor's note: In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.]

Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception).

Taking lessons from the work done by the associations of persons living with HIV/AIDS at the community level, Rwanda dedicated two other village-elected CHWs, one woman and one man, to dealing solely with end-of-life issues. These CHWs are responsible for caring for people in the late stages of any disease, which helps ease the burden on family members. Their care also decreases the number of dying patients brought to the hospital.

CHW explaining how to feed children and the meaning of the growth chart outside a house. Photo by Cathy Mugeni.

As there continues to be a high maternal morality rate in Rwanda, the Government is also training traditional birth attendants as CHWs to promote birth delivery at health facilities. CHWs are paid for every delivery they transfer to the local health center.

All activities are included in the health reporting system through reports that CHWs give to the Executives Secretary of each Sector, who in turn report activities to the Director of Health at the District level. At present, CHWs are all volunteers, but the Government of Rwanda is working on compensating these workers with performance-based financing and helping them to create cooperatives.

In conclusion, the five CHWs per village create community ownership, since it is the community who elected them. They also improve access to care and decrease hospitalization through what they manage at the community level. The harmonized training of all CHWs throughout the country is key. Community health workers are a smart and unavoidable solution that enables effective health care to bypass a lack of infrastructure in a resource-constrained country.

The UNHCR report Witchcraft allegations, refugee protection and human rights: a review of the evidence points out that witchcraft provides an answer to the question “why me?” when misfortune strikes. Unfortunately for many areas in Africa and elsewhere in the world, misfortune seems to be striking with vengeance. Particularly in countries where the people have been scarred by war, famine, economic collapse, death, and HIV infections, there are many “why me?” questions to be answered. As Father Horácio Caballero, director of a shelter that cares for children accused of witchery in Angola, says, “when AIDS begins to kill, someone in the family gets blamed for it.” Other children in Angola have been accused of transforming into animals and eating crops at night. Yet scientific analysis found that late rains had caused poor crop yield during that period.

Some common traits in children accused to have witchcraft are: stubbornness, learning disabilities, physical disabilities such as epilepsy, unruly behavior and not taking school seriously. Many of these traits deemed “witch-like” are usually considered normal adolescent behavior in the West. Children suffering from disease such as AIDS and malaria are also prime targets of witchcraft accusations.

While Father Caballero demonstrates the concern many clergy have to protect children from such accusations, not all religious and spiritual leaders share his understanding. Clergy play a large role in advising communities and families on which children are involved in sorcery. Children exhibiting traits as mentioned above are often brought to the local pastor or village healers for diagnosis. Arnold Mushiete, a social worker helping children accused of witchcraft in Kinshasa, Congo suggests that in a culture of death and broken family units, parents are very easy prey for greedy, ruthless clergy.

Religious and spiritual leaders may blame economic problems and health issues on the family’s weakest members. Sometimes clergy or healers are paid to perform exorcisms or “deliverance” ceremonies, thus increasing the incentive to “identify” witches in the family. Some pastors charge up to US$50 in Congo, which is an exorbitant fee considering the average annual salary is US$100. Save the Children’s The Invention of Child Witches in the Democratic of Congo report found that revitalized churches operate on a profit-making basis and will practice exorcism for financial gain.

Many children are often abandoned on the streets. Save the Children estimated that 70 percent of the 15,000 street children in Kinshasa have been accused of witchcraft.  Unfortunately, witchcraft has also been used as a pretext for abandoning unwanted children. Girls accused of witchcraft and abandoned face particularly horrific fates. Without protection, they are often raped and forced into prostitution.

Movements for banning the practice of condemning a child to witch craft are growing but still few. Akwa Ibom state in Nigeria has added a new clause to the Child Rights act, sentencing anyone found guilty of branding a child a witch to up to 12 years in prison. During his visit around Africa, the pope also spoke out against the practice of witchcraft and the use of Christ name to justify violence against children. Recently, videos documenting the plight of children accused of witchcraft have been released. To protect children from such severe human rights violations, more education of the population and government enforcement of child protection are needed.

This first explicit statement from the Pope on the subject was congruent with previous Vatican statements that moral and devout abstinence, in place of condoms, should be the primary prevention strategy. However, Pope Benedict went further, claiming that distribution and use of condoms increases the problem and can in fact spread the virus. The scientifically incorrect statement, which conflicts with knowledge on the proven effectiveness of condoms, jeopardizes the human right to “share in scientific advancements and benefits” as written in Article 27 of the UDHR. In a global outcry, health officials and religious leaders asserted that the Pope’s disregard of scientific evidence is extremely dangerous given the strong influences that Catholicism and its leader have in Africa.

When used correctly, condoms reduce the risk of viral transmission, although accurately testing condom effectiveness through randomized controlled trials is “logistically and ethically impossible.” Condom-based prevention strategies have also proven to dramatically decrease infection rates in large populations. Pope Benedict’s statements about the dangers and ineffectiveness of this widely used contraception, therefore, are not only morally charged but also globally devastating.

Nicholas Kristof of The New York Times wrote that the Pope’s words were among the Church’s “most tragic mistakes in the first two millennia of its history”; The Lancet reported that such a “false scientific statement…could be devastating to the health of millions of people.” Days after Pope Benedict’s speech, UNAIDS released a reactionary statement about the effectiveness of condoms and the importance of their distribution.

By placing a moral price on an effective and proven prevention method, is the Catholic Church robbing vulnerable populations of their right to “life, liberty, and security of person” (to cite article 3 of the UDHR)? Pope Benedict’s recent words transcended moral tolerance into the realm of science. When do religious statements overstep moral boundaries, confront human rights, and demand global refutation?

The international reaction was prompt and angry. The Pope’s influence, many said, could hinder HIV prevention, and result in setbacks for many condom-based prevention strategies in place. The position of the Catholic Church on condoms raises important questions about the impact of dogma on disease: will the Pope’s words have an impact on prevention efforts? The global reaction implies that an abstinence-only approach disregards the complex ways that AIDS, as Paul Farmer writes, moves “along the fault lines of our inter-linked societies.” Such an international reaction to the Pope’s anti-condom campaign identifies at its pulse some of the inextricable links between religion, society, HIV, and human rights.

Pope Benedict’s speech in the news:

Pope claims condoms could make African crisis worse

Global Challenges: Condom Distribution Not Answer to Curbing Spread of HIV in Africa, Pope Benedict Says

AIDS agency takes issue with the Pope

AIDS activists blast pope’s rejection of condoms

Influence of Catholicism in Africa:

On Africa Trip, Pope will find place where Church is surging amid travail