Part I- To Get Inspired, Build Empathy into Your Project Plan

~Written by Lauren Spigel, Monitoring and Evaluation Coordinator (Contact: lauren.spigel@vaxtrac.com; Twitter: @vaxtrac)

Also published on VaxTrac blog

Build Empathy First
In our first blog post about human centered design, we talked about building empathy for design thinking. But what does “empathy” really mean, and how does it translate into research methodology?

To have empathy is to understand another’s perspective. If your goal is to build empathy with the community you’re designing for, it’s important to budget time, space and resources to talk to a variety of project stakeholders about the challenge you’d like to solve before the project starts. While it’s difficult to convince donors to spend money on an extended R&D phase, giving communities a voice at the onset of your project can save your organization time and money by allowing stakeholders to voice their opinions and be active participants in the design process.

The methods we use to build empathy are reminiscent of the research methods found in academic settings. Human centered design is especially akin to the philosophy of community based participatory research (CBPR), which also recognizes that when given a voice, communities are best equipped to identify sustainable solutions to challenges they face. Like CBPR and more traditional qualitative research methods, human centered design relies on interviews, focus groups, observations, surveys, card sorts, among other interactive methods, such as role plays, immersion and community mapping to elicit feedback from stakeholders.

Let’s dive into the case example of how we are building empathy with health workers in Nepal to improve our user interface and workflow.

The Problem
The clinics we work with in Nepal are fundamentally different than the clinics we work with in Benin. In Benin, the clinics are urban and busy. There are vaccination sessions almost every day. Caregivers bring their children to the clinics for vaccinations.

By contrast, the clinics we work with in Nepal are rural. The population is dispersed. As a result, vaccinations only happen a few days a month. There may be one or two sessions that take place at the main clinic, but there are usually also a number of outreach sessions, in which the health workers walk several hours to sub-health posts within their catchment areas. Since the population is small, only a few children come to each session.

Building Empathy through Brainstorming and Workflow Cards
There are a number of methods we could use to get into the mindset of the health worker. The key is to remember that health workers are the experts. They understand their job better than anyone else. Our job is to listen, build empathy for what they experience in their jobs and translate that into our software design.

We are starting with the goal of understanding health workers’ workflows in different situations. In other words, what do health workers do to prepare for a vaccination session? What happens during a session? What happens after?

Our DC-based team started by brainstorming objects, people and actions involved in a vaccination session. We scoured the internet for images to represent everything that we came up with. We put together sample workflow cards and brought it to our project partners in Nepal.

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Draft Workflow Cards (Source: vaxtrac.com)

Seeing the sample workflow cards inspired our in-country partners Amakomaya to continue the brainstorm. They looked at our cards and told us what images worked and which images did not convey the right meaning. They grabbed a marker and started brainstorming their own list. We sketched images together.

We designed an interactive activity with health workers to use the workflow cards to get a better understanding of the different workflows they use during vaccination sessions. We are currently working to add Amakomaya’s feedback into an updated version of the workflow cards, which we will test out with a group of health workers early this year.
Using cards with simple images on them is a great way to get health workers talking about how they do their work. Cards are tangible objects that health workers can put in their hands and arrange in different ways. It gives the group a visual to refer to when someone has a question. It allows our team and health workers to identify gaps in the work flow as well as pain points.

We hope that by understanding current workflows and processes, we can understand the challenges that health workers face in their daily jobs and iterate our software so that it improves their workflow.

Check out our next post in our series about human centered design next week, where we’ll give examples of how we’ve been prototyping a monitoring and evaluation dashboard with our team in Benin.
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To learn more about incorporating design thinking into your projects, contact Lauren at lauren.spigel@vaxtrac.com or check out IDEO’s resources

Climate Change and Health, Part 2: Droughts, Food Insecurity and Culture

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

In my last blog post, I highlighted how climate change has impacted the frequency, severity and onset of floods, thus, have various impacts on the health and well-being of flood victims. In this blog, I will be discussing how food security will be impacted by climate change.

Overall, an increase in temperature would lead to a decrease in nutrient acquisition in crops and could disturb general nutrient cycling (St.Clair & Lynch, 2010). This would also cause an increase in the decomposition of soil organic matter, thus, reducing the fertility of soil and possibly impacting crop nutrition (St.Clair & Lynch, 2010).

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"Representation of the 11 Signs of Climate Change." Source: A Students Guide to Global Climate Change, Environmental Protection Agency (EPA)

Borana, Ethiopia is one region where droughts have been severe (Megersa et al., 2013). In this area, cattle ownership not only provides milk, an important part of the diet, but also indicates attaining the socio-cultural status set by the community. With an increase in temperatures, rangelands in this area have dried up. As there is less land for grazing, there has been a great loss in the number of cattle, and a reduction of milk produced by surviving cattle. This has led to negative health consequences as stunting has become more prevalent among children (Megersa et al., 2013). There has also been an increase in physical ailments among adults (Megersa et al., 2013). With this, 77 percent of households have claimed to be food insecure for over five months per year (Megersa et al., 2013).

As revealed in the above example, issues of food security can be closely associated with cultural norms, as diet is often influenced by the local tradition. Thus, when there is a decrease in what is considered to be a staple-food in the region, a diversification in diet can help alleviate food insecurity (Megersa, Markemann, Angassa, & Valle Zárate, 2013). However, adapting to dietary changes can be a difficult process, especially when diets are so deeply rooted in traditions (St.Clair & Lynch, 2010). Cultural norms also influence how vulnerable populations are impacted by food insecurity. For example, issues of food insecurity related to climate often leads to more issues for women and children because they are already lower on the “food hierarchy” (Watts et al., 2015).

The recent article on climate change and health published by the Lancet discussed many potential options for adaption (Watts et al., 2015). For example, efforts should be made to improve ecosystem management (Watts et al., 2015). Investments should also be made in agricultural research in order to increase food security for the long-term (Watts et al., 2015). Furthermore, early warning systems and food reserves also need to increase in order to potentially avoid issues of nutritional deficiencies (Watts et al., 2015).

As often, this issue is complicated, and there are several questions that can be asked. For example, how can policies be formed to alleviate the impacts on the most vulnerable populations? Furthermore, should those in high-resourced countries be concerned about how those in low-resource regions could be impacted by an increase in droughts? Or even how those living in developed countries could also be impacted by these droughts? 
Or is the problem maybe too far from home to be a concern in the first place?


References:
Megersa, B., Markemann, A., Angassa, A., & Valle Zárate, A. (2013). The role of livestock diversification in ensuring household food security under a changing climate in Borana, Ethiopia. Food Security, 6(1), 15–28. doi:10.1007/s12571-013-0314-4

St.Clair, S. B., & Lynch, J. P. (2010). The opening of Pandora’s Box: climate change impacts on soil fertility and crop nutrition in developing countries. Plant and Soil, 335(1-2), 101–115. doi:10.1007/s11104-010-0328-z

Watts, N., Adger, W. N., Agnolucci, P., Blackstock, J., Byass, P., Cai, W., … Costello, A. (2015). Health and climate change: policy responses to protect public health. The Lancet, 6736(15). doi:10.1016/S0140-6736(15)60854-6

Aid Dependency: The Damage of Donation

~Written by Victoria Stanford, University of Edinburgh (Contact: vstanford@hotmail.co.uk)

"The Culture of Aid Dependency Need to Change," David Sengeh, Sierra Leone. Photo Credit: www.engineeringforchange.org

Aid has long been the response of richer countries to the imbalance of economic development seen across the globe. In the last two decades however, relatively non-intrusive in-kind giving has been re-branded and intensified to the point where aid today is arguably used as a strategic force in increasingly interventionist global development policy. The aid industry has seen a rapid expansion, characterised by an increase in the number of organisations, amounts of funding and geographical reach (Collinson and Duffied, 2013). The question of aid dependence is an important one; many argue that international assistance paradoxically poses a barrier to recipient country development and sustainable economic growth (Moyo, 2009).

Recent rhetoric surrounding aid dependency is clear- it is an unwelcome and unfortunate side effect of aid and its diminishment is high on the aid policy agenda (Thomas et al., 2011). What is becoming increasingly clear however is that there is an emerging type of aid-related dependency that does not refer to economic or financial factors, but political. Cases of corruption in recipient country governments have been met with the development of more complex modes of donation, including direct programme funding, conditionalities, tied aid, and grants, which give donors more control over the direction and ultimate use of their funds. This often means that those providing aid are increasingly entwined in political processes. This combined with aid uncertainty, questionable sustainability, and a tendency of top-down approaches to political involvement, create a situation where countries in need of aid are dependent upon foreign agendas.

How has aid caused dependency?

Aid dependency refers to the proportion of government spending that is given by foreign donors. Since 2000 this has in fact decreased by one third in the world’s poorest countries, exemplified by Ghana and Mozambique where aid dependency decreased from 47% to 27% and 74% to 58% respectively (3). Aid is not intrinsically linked to dependency; studies have shown that dependency is influenced by many factors, mostly length and intensity of the donation period, and 15-20% has been identified as the tipping point where aid begins to have negative effects (Clemens et al., 2012). What causes dependency is when aid is used, intentionally or not, as a long-term strategy that consequently inhibits development, progress, or reform. Food aid is particularly criticised for this; increasing dependency on aid imports disincentivises local food production by reducing market demand. This is compounded when declining aid is replaced with commercial imports rather than locally-sourced food, either because of cheaper prices or a lack of recipient country food production capacity because of long-term aid causing agricultural stagnation (Shah, 2012). This is exemplified in the situation of Haiti, which is dependent on cheap US imports for over 80% of grain stocks even in a post-aid era, or countries such as the Philippines where aid dependency has forced an over-reliance on cash crops. Dependency relates not only to commodities but also technical expertise and skills which donors often bring to specific aid schemes and projects, which when not appropriately coupled with education create an over-reliance on donors (Thomas et al., 2011).

A more concerning type of dependency

The nature of aid almost intrinsically causes what is increasingly known as ‘political dependency’ by encouraging donor intervention in political processes. Donors need to satisfy the interests, values and incentives of the home country, whilst also providing them with expected results in order to maintain the cash flow. This has resulted in donors either bypassing and therefore destabilising government service provision processes to establish donor projects, a strategy often favoured by USAID and the World Bank (Bräuntigam and Knack, 2004), or intervening directly in policy-making and implementation (Bräutigam, 2000).

The involvement of donors, either foreign governments or international agencies, in recipient country political processes has been shown to reduce the quality of governance (Knack, 2001). It reduces leader accountability; the government is “playing to two audiences simultaneously”- the donors and the public (Hayman, 2008). This means the direction of accountability is between government and donor rather than the public, risking government legitimacy and delaying the progress of political reform and development (Bräutigam, 2000). This is particularly damaging in countries where the need for aid stems from political upheaval or civil unrest such as the Democratic Republic of Congo or Zimbabwe, which have a lengthy history of aid dependence (Moss et al., 2006). The risk here is that donors have political leverage, thus decisions and planning become reliant on donor involvement whose motivation and values may not necessarily align with those of the public or government.

Furthermore, ‘earmarking’ is a strategy favoured by many international donors who fear corruption in recipient governments, therefore ‘earmark’ direct sector or programme funding rather than general government budget support (Foster and Leavy, 2001). This not only shifts the agenda-making power to donors who have the authority to set priorities and direct funds accordingly, but also creates patchy and unsustainable development where some sectors outperform others.

An additional significant problem of dependency upon international agenda-making for countries receiving aid is that globally recommended ‘best practice’ policies often lack appropriate contextualisation to cultural, religious, or social values. A top-down, uniform approach to policy implementation by donors also has logistical barriers whereby local infrastructure is incapable of carrying out donor projects effectively and producing satisfactory results. A good example of this is the widely-disseminated policy encouraging syndromic management of sexually transmitted diseases, which was coercively incorporated into aid channels in Mozambique, despite the clear lack of the technical expertise and human resource capacity that such a robust policy requires (Cliff et al., 2004). This then perpetuates aid dependency because donors do not receive satisfactory project results and may consequently reduce funding without actually solving the problem, thus the poverty cycle continues and aid is required once again.

Demolishing aid dependency

Ending or preventing aid dependency will be contingent on affirmative action from both donors and recipients. Botswana is a key example of recipient-led aid policy that effectively resulted in rapidly reducing aid and therefore dependency. Botswana began receiving aid shortly after gaining independence in 1966 (Bräutigam and Botchwey, 1999). Of primary importance here is that Botswana largely decided the direction and use of funding; areas of priority were identified and donors were matched accordingly, thus avoiding reliance on donor ideas and agendas. Only projects that the predicted government capacity could absorb once aid was reduced in the long-term were undertaken, which ensured sustainability. In contrast, the relative ‘success story’ of Taiwan can be explained by donor-led project planning. Taiwan received much aid from the US in the early 1960’s which focused mainly on building infrastructural capacity-docks, railways, factories-with the aim to increase trading systems and boost the economy. In fact, this scheme was so effective that the US eventually withdrew aid for fear of creating competition (Chang, 1965).

It seems evident that recipient-led schemes and projects are more effective and reduce the risk of dependency. Technically speaking, some argue that aid should only ever be in the form of general government budget support rather than selective sector or project aid because it reduces donor involvement in political processes. It is also less bureaucratic, is less influenced by donor missions who need to produce and report results, and avoids the risk of uneven service provision (Moss et al., 2006). Ideologically speaking, the aid industry today is at risk of forming a novel kind of colonialism where ‘Western’ ideas of development and progress are used to influence and hold power over governments of countries receiving aid.

Concluding thoughts

The aid industry must respond to the problem of economic and political dependence. Coordinated efforts to more effectively monitor donor-recipient relationships, using a widely implemented human rights-based legal and moral framework for aid policy should be the ultimate, collective goal (Ooms and Hammonds, 2008). The reality is however that with increasingly complex humanitarian disasters and the destructive forces of climate change looming, the aid industry will be called upon to increase capacity and intensity which may perhaps re-direct focus from implementing ideological change. Nevertheless, the opportunity to ‘get things right’ in aid policy and practice persists, and it is a moral imperative that the industry and its participants make the attempt.

References:

Bräutigam D and Botchwey K (1999) The institutional impact of aid dependence on recipients in Africa. Chr. Michelsen Institute;Working Paper 1.

Bräutigam, D. (2000). Aid dependence and governance, Almqvist & Wiksell International;Stockholm pp.14.

Bräuntigam D and Knack S (2004) Foreign aid, institutions and governance in Sub-Saharan Africa, Economic Development and Cultural Change, Vol 52;2, pp.255-285.

Chang D (1965) US Aid and Economic progress in Taiwan, Asian Survey, Vol 5;3, pp.152-160.

Clemens MA, Radelet S and Bhavnani R (2012) Counting Chickens when they Hatch: Timing and the Effects of Aid on Growth, The Economic Journal, 122(561), 590-617.

Cliff J, Walt G and Nhatave, I (2004) What's in a Name? Policy transfer in Mozambique: DOTS for tuberculosis and syndromic management for sexually transmitted infections. Journal of Public Health Policy, 25;1, p.38-55

Collinson S and Duffied M (2013) Paradoxes of Presence:Risk Management and aid culture in challenging environments, Humanitarian Policy Group, Overseas Development Institute [Online] Available at: http://www.odi.org/sites/odi.org.uk/files/odi-assets/publications-opinion-files/8428.pdf [Accessed 02 January 2015].

Foster M and Leavy J (2001) The choice of financial aid instruments. London: Overseas Development Institute, pp.4.

Hayman R (2008) Rwanda: milking the cow. Creating policy space in spite of aid dependence. The Politics of Aid, 156.

Knack S (2001) Aid dependence and the quality of governance: cross-country empirical tests, Southern Economic Journal, 310-329.

Moss T, Pettersson G andVan de Walle, N (2006) An aid-institutions paradox? A review essay on aid dependency and state building in sub-Saharan Africa, Centre for Global Development; Working paper No. 74.

Moyo D (2009) Dead Aid, Penguin; London, pp.12

Ooms G and Hammonds R (2008) Correcting globalisation in health: transnational entitlements versus the ethical imperative of reducing aid-dependency. Public Health Ethics, 1(2), 154-170.

Shah A (2012) Food aid, Global Issues [Online] Available at: URL: http://www. globalissues. org/article/748/food-aid [Accessed January 02 2015]

Thomas A, Viciani L and Tench J et al (2011) Ending Aid Dependency, Action Aid; London.

Climate Change and Health, Part 1: Floods

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

The Lancet recently published an article on climate change and health, extensively examining the types of health risks related to climate change as well as recommendations for policy changes, in order to address these risks (Watts et al., 2015). This article re-emphasized how complex this issue is because there are several contributing factors, and elements that can be potentially impacted (Figure 1).  As there are so many aspects of this topic, for my next few blog posts I will focus on briefly highlighting some of the health risks associated with climate change. This post will focus on natural disasters, specifically looking at floods.

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Figure 1: Relationship between health, climate change and greenhouse gas emission (Watts et al., 2015)

Since 1900, floods have left more than 88 million people homeless, $595 billion in damages, and the deaths of nearly 7 million people (Khedun & Singh, 2013). Overall, climate change will have a direct impact on human health through natural disasters, such as flooding. South Asia is especially at risk as there is already regular flooding. A change in climate can affect the onset of monsoons. For example, in Kerala, a state in southern India, the monsoon season generally begins on June 1st and ends in early September, with a standard deviation of about seven days (Mirza, 2011). However, in the last 50 years this has more than doubled with the earliest onset on May 14th, and the latest date of onset on June 18th (Mirza, 2011). While this may not seem significant, it can influence the level of preparedness in communities that are at risk. Furthermore, the frequency and intensity of rainfalls will also increase. According to climate models, monsoon intensity increases during the summer, as the air over land is warmer than air over the oceans (Mirza, 2011). Floods, that result from the monsoon weather, not only increase the risk of drowning, but also affect the quality of water, thus increasing the exposure to waterborne diseases such as dysentery and diarrhea (Mirza, 2011).

Mental health issues, such as anxiety and depression, can also develop after losing property or facing a financial crisis after a flood (Khedun & Singh, 2013). Furthermore, the impacts of climate change, such as increased flooding, disproportionately influence certain populations such as marginalized communities, women, children, and the elderly (Watts et al., 2015). Thus, they suffer most of the negative health consequences associated with flooding and other disasters related to climate change (Watts et al., 2015). This highlights the complexity of the issue in terms of trying to address how to help those who are most impacted by floods.

There are several mitigation efforts that can be taken in order to reduce the impact of floods. For example, urban planners and engineers can work to ensure that forested areas are preserved and development occurs in areas where soil and vegetation conditions work best to reduce the risk of flooding. Many non-structural methods can also be implemented. For example, in some areas it may be beneficial to create zoning laws that would prohibit development in areas that are prone to flooding (Watts et al., 2015). Government officials and private officials can also work together to improve early warning systems and develop better policies for flood-insurance and emergency preparedness (Watts et al., 2015). Taking these steps can help to ensure that health issues associated with floods will not be exacerbated.

References:

Khedun, C. P., & Singh, V. P. (2013). Climate Change, Water, and Health: A Review of Regional Challenges. Water Quality, Exposure and Health, 6(1-2), 7–17. doi:10.1007/s12403-013-0107-1

Mirza, M. M. Q. (2011). Climate change, flooding in South Asia and implications. Regional Environmental Change, 11(SUPPL. 1), 95–107. doi:10.1007/s10113-010-0184-7

Watts, N., Adger, W. N., Agnolucci, P., Blackstock, J., Byass, P., Cai, W., … Costello, A. (2015). Health and climate change: policy responses to protect public health. The Lancet, 6736(15). doi:10.1016/S0140-6736(15)60854-6

Investing in Healthcare to Put a Dent in Poverty

~Written by Hussein Zandam (Contact: huzandam@gmail.com; Twitter: @zandamtique)

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Poverty and Healthcare, Two halves. Photo credit: Our Africa

Health and poverty are intricately related. Evidence suggests that there is a positive correlation between health and poverty. People with limited resources in low- and middle-income countries (LMICs) are reported to have limited access to healthcare compared to their wealthier counterparts (Wagstaff, 2002). However, other evidence has shown that health expenditure can push households into poverty (Kruk et al, 2009). Tackling either is a priority for governments to improve the welfare of people. The poor are more likely to need healthcare for many reasons including a lack of safe drinking water, a balanced diet, adequate shelter, and protection against harsh environmental conditions. Because of the increased need for healthcare, the poor incur increased spending on already limited resources, and are likely to experience catastrophic expenditure. Reducing healthcare expenditure by the poor has the potential to be a viable mechanism against deepening of poverty.

Reducing extreme poverty is a major goal of the Millennium Development Goals (MDGs) and was also considered in the formulation of the post-2015 agenda. Countries all over the world are grappling with measures to reduce income inequality and poverty. In developing countries, this is more apparent through the increase of micro credit schemes, subsidies, and social safety nets for the most vulnerable. However, evidence has shown that in spite of efforts from nations and development partners, more needs to be done to eradicate extreme poverty (Laterveer et al. 2003). Poverty and access to healthcare have been subjects of research and policy. Poverty can be viewed not only as a conception of material and income deprivation (Deaton and Zaidi, 2002) but also as the lack of opportunities for an individual to lead a life he/she values (Sen, 1999). Using this concept, empowering people to live healthy lives can be seen as an initiative to overcome poverty. However, when poverty is viewed as a deprivation of income and assets, initiatives are channeled that directly improve household expenditure; when in relation to health, initiatives that lower expenditure on health to avoid catastrophic expenditure.

The World Health Organization (WHO; 2000) has advocated for health financing measures that provide financial protection from catastrophic health expenditure. Catastrophic expenditure is a leading cause of impoverishment in many countries. Efforts to prevent catastrophic expenditure oh health have been primarily through insurance. However, in many LMICs it is not effective and/or is beyond the reach of the poor either by being too costly or by not providing adequate coverage (McIntyre, 2006). Thus, the world health report (WHO, 2010) advocated for universal public finance (UPF) as a strategy to promote universal health coverage. UPF means that governments finance interventions for people regardless of who receives it and who provides it. UPF has been in practice in many high-income countries where many necessary interventions are covered. In LMICs however, UPF is limited by targeting a set of interventions tagged as the essential health package, which means many services are excluded and require user payments at the point of care.

For example, extended cost-effectiveness analysis (EECA) was used to assess the effectiveness and reduction in financial risk afforded by a public package of interventions initiated by the government of Ethiopia (Verguet et al, 2015). The interventions examined included services for vaccination, treatment of some conditions, caesarean section surgery, and tuberculosis DOTS. Their analysis focused on UPF where there is no out-of-pocket expenditure to cover costs incurred for each of the nine interventions. They estimated the annual number of deaths averted and the annual total financial protection afforded by the reduction in out-of-pocket expenditure associated with each intervention. The results for intervention costs, health gains and financial protection varied across the interventions but it was concluded that the interventions were cost-effective and prevented cases of poverty among those at lowest income level. Such evidence can be used to convince governments to increase funding of health services with the objective of improving health status of citizens and eradicating extreme poverty among the population.

References:

Deaton, A. and Zaidi S. 2002. Guidelines for Constructing Consumption Aggregates for Welfare Analysis. World Bank. https://openknowledge.worldbank.org/handle/10986/14101. 

Kruk et al. 2009. Borrowing and selling to pay for health care in low- and middle-income countries. Health Aff. 28: 1056–66.

Laterveer et al. 2003. Pro-poor health policies in poverty reduction strategies. Health Policy Plan. 2: 138–145.

Mcintyre et al. 2006. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc. Sci. Med. 4: 858–865.

Sen, A. (1999). Development as Freedom, Oxford University Press, Oxford, 1999.

Verguet et al. (2015): Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis. Lancet Glob Health 2015; 3: e288–96.

Wagstaff, A. 2002. Poverty and health sector inequalities.Bull. World Health Organ. 80: 97–105.

WHO (2000). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2000.

WHO (2010). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2010.

Implementing Sustainable Wastewater Treatment Methods to Reduce the Risk of Waterborne Diseases

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com; Twitter: @joann_s_v)

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Bello Wastewater Treatment Plant, Medellin, Colombia (Photo Credit: www.water-technology.net)

The discharge of household and industrial waste can lead to the spread of waterborne diseases if left untreated because of cross contamination with drinking water or other forms of direct contact (Daley et al., 2015). This issue of wastewater sanitation has become prevalent in several low-resource countries, as the treatment of wastewater can often be expensive, and the policies needed to implement low-cost methods do not exist. 

One example of this is in Kenya, where sustainable water management practices have yet to be implemented. Furthermore, rapid urbanization and population growth have contributed to this problem (Mburu et al., 2013). Overall, due to the low operational capacities, only 5 percent of the country’s sewage is properly treated (Mburu et al., 2013). Thus, untreated or partially treated domestic wastewater is discharged into local freshwater rivers and lakes, leading to severe contamination. This not only results in the prevalence of diseases such as cholera, but it can also lead to high economic costs due to a decrease in work productivity as well as strains on the healthcare system (Mburu et al., 2013).  

Colombia has also faced issues due to ineffective wastewater treatment. While this country has not had issues of water quantity, the issue of water quality remains a problem. In some areas, nutrients, suspended solids and organic matter can be effectively removed using existing methods; however, in some areas, treatment can be difficult due to geographic location and/or cost (García, Paredes, & Cubillos, 2013). Nevertheless, many of the current systems are unable to successfully remove pathogens, which can eventually lead to waterborne diseases (García et al., 2013). 

When examining wastewater treatment in any region, in this case low-resource countries such as Kenya and Colombia, sustainable methods must be implemented. Constructed wetlands (CWs) are a possible method that can be used to improve wastewater sanitation. Characterized according to the water flow direction in the system, CWs have been implemented in various regions over the years to treat polluted water (García et al., 2013). These planted and unplanted systems have proven to remove heavy metals, nutrients and pathogens. For example, horizontal subsurface flow constructed wetlands (HSSF-CWs) have been successfully implemented for over four decades in developed countries with temperate-climates. The use of CWs has proven to be inexpensive, as it has minimal energy requirements and low maintenance needs (García et al., 2013). Thus, implementing these systems could greatly benefit many regions, and especially those that are currently facing health risks associated with wastewater treatment. 

This issue, like many others related to public health, is complex. Policy-makers, engineers, and health professionals are among the many groups that need to work together to ensure that such systems can be effectively implemented and monitored in order to reduce the health risks that are associated with contaminated water. 

References:

1.      Daley, K., Castleden, H., Jamieson, R., Furgal, C., & Ell, L. (2015). Water systems, sanitation, and public health risks in remote communities: Inuit resident perspectives from the Canadian Arctic. Social Science & Medicine, 135, 124–132. doi:10.1016/j.socscimed.2015.04.017

2.      García, J. a., Paredes, D., & Cubillos, J. a. (2013). Effect of plants and the combination of wetland treatment type systems on pathogen removal in tropical climate conditions. Ecological Engineering, 58, 57–62. doi:10.1016/j.ecoleng.2013.06.010

3.      Mburu, N., Tebitendwa, M., S., Rousseau, P.L., D., Bruggen, J. J. A. Van, & Lens, N.L., P. (2013). Performance Evaluation of Horizontal Subsurface Flow-Constructed Wetlands for the Treatment of Domestic Wastewater in the Tropics. Journal of Environmental Engineering, 139(March), 1152–1161. doi:10.1061/(ASCE)EE.1943-7870

Global Health in a 'Restricted' Country - Breaking the Barrier of Stereotypes

~Written by Dr. Sulzhan Bali, Director of Production and HR, TWiGH (Contact: sulzhan.bali@twigh.org)

*Also published on the Duke Global Health Institute Page "Diaries from the Field Blog"

                                            Lagos, Nigeria - a vibrant city

Let’s play a game. Shall we?  I give a word and you think of the first word that comes to your mind.

Nigeria.

Pat yourself on the back if the word you came up with was NOT ‘scam’, ‘419’, or ‘Boko Haram’. Treat yourself to a chocolate if the word that you came up was a positive word (and if you are not Nigerian).

You see, stereotyping comes naturally to our species. Often, our outlook is dictated by the media, news, and hearsay- which although important, often gives us an incomplete singular dimension of the holistic picture.  Unfortunately more often than not that singular dimension dictates our biases.

 I must admit, before I arrived to Nigeria for field-work, I was afraid. Afraid of what awaited me on the other side. After hearing reactions such as “Why Nigeria out of all places?”, “stay careful in Nigeria, scamming is so common”; “Oh no! Isn’t that where Boko Haram is?”, and tales of evacuation, kidnappings, and even carjackings- I had started really wondering whether I should be excited at all? It didn’t help that my field-work country site was considered entirely restricted for safety purposes. No wonder, I was a little nervous as I disembarked the plane.

After I landed, my first experience of Nigeria was a man offering help at the airport for the cart. I didn’t have local currency yet and I needed a cart for my luggage.  I remembered of the innumerable warnings by friends and family to keep my wits about and to trust no one.  Did I take his help? Yes. Did he run away with my bags? No. Over the course of next 2 weeks, I would discover each and every Nigerian that I met to be warm, friendly, helpful, and yes- trustworthy!  

The risk of being scammed or cheated exists in every big city and Lagos is no different. This city of 21 million people is a melting pot of cultures and like any other metropolitan city in the world is like a coin with 2 sides.  My time in Lagos so far has turned my idea of Nigeria that I had upside down. Yes, there is poverty. Yes, development is an issue. So is corruption, weak health system, malaria, maternal mortality, and infant mortality. Yet, there is also will power.  There is optimism. There is an incredible spirit of entrepreneurship, which I am yet to see in another part of the world. Every Nigerian is an aspirational entrepreneur, hustling to be a successful one. People have a safe job along with an entrepreneurial venture. No wonder, that in Nigeria 41% of women between 18-64 years are entrepreneurs- the highest in the world! Unfortunately, Nigeria also ranks among the worst 20 countries in the world for women entrepreneurs. Many of these entrepreneur women are small traders or market women and entrepreneurship is a by-product of necessity due to lack of opportunities in the formal sector. Yet, despite it all, there is no denying the fact that entrepreneurial energy in Nigeria is on a high. There is an impressive desire in almost all Nigerians that I have interacted with to build something of their own. Optimism and innovation have overshadowed the constraints of red tape and lack of infrastructure. Many entrepreneurs in Nigeria are in it to make an impact and facilitate social change. An apt example is EbolaAlert- an organization that I am collaborating with for my study on 'Role of Private Sector in Ebola Response in Nigeria'. EbolaAlert started as a twitter handle at the peak of Ebola Outbreak in West Africa. People across the world were getting their accurate information on the Ebola Outbreak through it. What started as an information-providing platform turned into a Global health influencer that is now launching multiple public health education campaigns across Nigeria in partnership with CDC, Unicef, MSF, and the private sector.

Global health is about collaboration and coordination. It is about dialogue between sectors, organizations, and cultures. To be able to do that successfully, one has to look beyond the biases. Casting away our lens of bias requires looking beyond what we see and hear in media, news, and hearsay which is only possible with a cultural immersion and an open mind. This is why field-work is such an important component of global health.  Nigeria is not perfect. No country ever is. As the biggest economy in Africa and a country all set to reap its demographic dividend, Nigeria has the means and the will to become a great nation. I recently met a few Nigerian young professionals in Lagos. These were Nigerians from across the world visiting for the Young Nigerian Leaders conference to talk about the future of Nigeria. As it happens, Nigeria's biggest assets are its people. Many of who are using lean entrepreneurship, collaboration and ideation to facilitate change in all spheres.  From my vantage point, the whole world is Nigeria's oyster. Restrictions on the other hand, lie only in our mind set. 

No prize for guessing which is the first word that comes in my mind when someone says Nigeria.  It is 'entrepreneurship'. 

Examining How Women are Influenced by Inaccessibility to Clean Water

~ Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

Since 1990, 2-3 billion people have gained access to improved drinking water sources, however, much is yet to be done, as billions still do not have access to safe drinking water (Dora, et al., 2015). This has led to several negative health consequences among many communities, as one-third of deaths are linked to the intake of contaminated water in low-resourced countries (West & Hirsch, 2013). Women are often responsible for housework such as cooking, cleaning and maintaining good hygiene. They are also mainly responsible for the care of children and the sick. As all of these tasks require the use of water, women in low-resourced countries are disproportionately affected by the inaccessibility to safe water.

Risks Associated with Water Collection

In 71 percent of households in sub-Saharan Africa women are responsible for collecting water (West & Hirsch, 2013).  As a result, in places such as the mountainous areas of Eastern Africa, women use up to 27 percent of their caloric intake to get water (West & Hirsch, 2013). Sometimes, they must travel a long distance, often several times in one day. This can lead to physical strain, especially among the elderly. This strain can be exacerbated by extreme heat or with heavy pumps at well sites. Water collection can also be dangerous in remote locations where there is increased risk of rape or other forms of violence.

Impacts on Women as Caretakers, and the Terminally Ill

With a high prevalence of HIV and AIDS in these regions, there has also been an increase in care needed for the terminally ill, and once again, it is the responsibility of the woman to provide the needed care (West & Hirsch, 2013). This involves emotional support, but also other aspects such as bathing and toileting. Providing this type of assistance can become more difficult when there is little accessibility to clean water. Furthermore, caregivers also have an increased chance of developing physical pain and infections because of the risks they are exposed to. Increasing accessibility to clean water will not only improve the outcomes of HIV treatment, but it will also reduce the burden of care on women. As a result, this can improve the quality of life for both groups (Figure 1).

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Figure 1: How improved water and sanitation influences the health of those with HIV/AIDS, and caretakers (West & Hirsch, 2013).

Overall, inaccessibility to clean water increases the emotional distress on women and reduces the level of care they are able to provide to those around them. When mothers have poor health status they are unable to provide the adequate resources needed for the well being of their children, which can lead to growth stunts (Requejo, et al., 2015).

Like any other public health issue, this one is complex. Many factors must be examined to determine how improvements can be made to increase the availability of safe water, while also empowering women. For example, while women have to travel long distances in order to get clean water, this also gives them a chance to socialize with other women and spend some time away from the home. Thus, what can be done to preserve this time for social interaction, while minimizing the health risks?  In order to answer this and similar questions, governments and NGOs must critically analyze social systems, specifically gender norms, health systems and physical infrastructure in low-resourced countries.

References:

Dora, C., Haines, A., Balbus, J., Fletcher, E., Adair-Rohani, H., Alabaster, G., et al. (2015). Indicators linking health and sustainability in the post-2015 development agenda. The Lancet , 385 (9965), 380-391.

Requejo, J. H., Bryce, J., Barros, J. A., Berman, P., Bhutta, P., Bhutta, Z., et al. (2015). Countdown to 2015 and beyond: Fulfilling the health agenda for women and children. The Lancet , 385 (9966), 466-476.

West, B. S., & Hirsch, J. S. (2013). HIV and H2O: Tracing the connections between gender, water and HIV. AIDS Behaviour , 17 (5), 1675-1682.  

The Role of the Built Environment in Reducing the Incidence of Type 2 Diabetes

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

Diabetes is a chronic disease that affects many people worldwide. Type 1 diabetes is an autoimmune deficiency that often develops in childhood and impacts about 10 percent of those with the disease (Canadian Diabetes Association, 2009). However, type 2 diabetes develops later in life, is influenced by environmental and lifestyle factors, and is prevalent among nearly 90 percent of those with diabetes.  While Type 2 diabetes used to be considered a “disease of the West”, it has now spread to more countries; thus, more efforts need to be made to reduce the incidence of this disease. As healthy diets and regular physical activity are key components to reducing the prevalence of type 2 diabetes, the built environment needs to be taken into consideration. The built environment includes all of the aspects of an environment created by humans, such as neighborhoods and cities, and consequently plays an important role in ensuring that people can access healthy food, and increase physical activity.

The Importance of Community Gardens

The accessibility of healthy foods can increase with the implementation of community gardens. Preliminary studies reveal several benefits of community gardens, including the associated increased intake of produce. One study examined the benefits of community gardens in South-East Toronto, concluding that those who participated in the maintenance of the garden increased their intake of vegetables and fruits and bought fewer produce from grocery stores (Wakefield, Yeudall, Taron, Reynolds, & Skinner, 2007). While these community gardens were established by non-governmental organizations, city planning officials still have a large role to play, as they could ensure that there is land in urban areas specifically designated for community gardens.   

Gardens could also be incorporated into schoolyards. One example of this was in California where the “Garden in Every School” program was implemented, and vegetables and fruits were grown on school property.  The kids helped to maintain the garden and this promoted healthy eating and an overall increase in the local food supply (San Mateo County Food System Alliance, 2010; Dannenberg, Frumkin, & Jackson, 2011).

The Role of Active Transportation

Encouraging physical activity is also a key component in reducing diabetes prevalence and this can be done through changes in the built environment by encouraging active transportaiton. This would involve increasing the walkability of communities through the implementation of pedestrian infrastructure, such as sidewalks and safe crossings, to ensure that these places are easily accessible.  

Encouraging “Smart Growth” would also be important. This concept was developed in the 1990s by initiatives that were being implemented by various organizations, including the American Planning Association (Dannenberg et al., 2011). “Smart Growth” policies encourage the preservation of open space, and making communities more walkable. This could be done through the implementation of mixed-land use development, which would ensure that employment, schools and shops were within close proximity and walking became one of the main methods of transportation.

Another key component of Smart Growth is developing a variety of transportation methods through the implementation of Transit-Oriented Development, which also became prominent in the 1990’s. This would be another way to encourage physical activity and reduce reliance on cars. Implementing bike lanes also encourages biking as a means of transportation. In Portland, Oregon there was an increase in biking after several miles of bike lanes were added, as a quadrupling in bikeway miles resulted in a quadrupling of bicycle bridge traffic (refer to Figure 1).

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Figure 1: An increase in bikeway miles in Portland, Oregon was led to an increase in bicycle traffic (Dannenberg et al., 2011).

There are other factors to consider when examining type 2 diabetes, such as biological factors among certain ethnic groups, and the difficulties associated with trying to make behavioural changes. However, by making sustainable changes to the built environment to increase accessibility to healthy foods and encourage active transportation, government officials and non-governmental organizations can begin to greatly reduce the prevalence of type 2 diabetes.  

References:

Canadian Diabetes Association. (2009). An economic tsunami of the cost of diabetes in Canada. Retrieved March 28, 2015, from http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/economic-tsunami-cost-of-diabetes-in-canada-english.pdf 

Dannenberg, A. L., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places: Designing and Building for Health, Well-Being, and Sustainability. Washington: Island Press.

Hu, F. B. (2011). Globalization of Diabetes: The role of diet, lifestyle, and genes. Diabetes Care , 34 (6), 1249-1257.

San Mateo County Food System Alliance. (2010). A Garden in Every School. Retrieved March 25, 2015, from Ag Innovations Network: http://aginnovations.org/images/uploads/call-to-action_GBL_final.pdf 

Wakefield, S., Yeudall, F., Taron, C., Reynolds, J., & Skinner, A. (2007). Growing urban health: Community gardening in South-East Toronto. Health Promotion Internationl , 22 (2), 92-101.

Health Issues on the African Horizon for 2015

~ Written by Mike Emmerich - Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich 

As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent's development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverageand is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

“Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW's.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW's numbers have been reduced as a result of war, poor political will and Ebola.

Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW's have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett's latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW's.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc...

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.