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.

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

Mother and Child in Bolivia

According to the World Health Organization (WHO), if you are a young Bolivian, you have a 6 percent chance of dying before your fifth birthday. Diarrhea and malnutrition, conditions rooted in poverty, are the leading causes of child mortality in the South American country. Against this background, a UNICEF-funded government health insurance plan will allow doctors to provide unrestricted care to children under the age of five as well as pregnant women. Bolivia’s health services still have much work to do to ameliorate the underlying causes of childhood diseases. UNICEF estimates that 2.5 million Bolivian children are living in poverty, leading to the compounded problem of chronic malnutrition.

While the UNICEF program, which covers the costs of the medical treatment of children, is an important step in making care readily available to Bolivians, the government still needs to reach out to the destitute rural and indigenous populations. Prohibitive distance and cost are not the only factors that separate these Bolivians from medical professionals. The systemic degradation of trust may stem from a communication barrier: Many doctors and nurses do not speak Quechua or Aymara (indigenous Bolivian languages). Cultural traditions, such as keeping a male child’s umbilical cord long to symbolize masculinity, or the association of white walls, such as those in hospitals, with the burial of babies, exacerbate the already dangerously poor health outcomes for these individuals. UNICEF’s health insurance program, while a critical first step in improving child life expectancy, will be unable to achieve lasting change in the most under-served populations until cultural dynamics, along with endemic poverty and rural inequality, are addressed.

More information on Bolivia below the fold.

WHO: Bolivia

UNICEF: Bolivia

Healthcare in Rural Bolivia