Government Policy

Community Engagement, Health Promotion, Government Policy

Community Gardens for Improved Community Health

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

Community Gardens in Developed Regions

Community gardens are either individual plots or collectively cultivated gardens, and there is often some form of public ownership (Jermé & Wakefield, 2013). There are various levels of commitment from local citizens. For example, NeuLand, a community garden in Cologne, Germany is run by a charitable organization with five paid staff members, a managing committee, about 20-30 committed gardeners, and about 40 occasional gardeners (Follmann & Viehoff, 2014).

In the Western World, community gardens have become popular because they are often viewed as a way to advocate for sustainable social and ecological change through a bottom-up approach (Follmann & Viehoff, 2014). Thus, they have proven to have an important impact on the health of citizens in various regions.

Health Benefits

Community gardens have specifically increased access to healthy foods in marginalized regions, consequently, alleviating issues of food poverty (Jermé & Wakefield, 2013). In order to increase the consumption of fresh vegetables, the Victory Garden program was founded in the United States during World War II (Armstrong, 2000; Chan et al., 2015). This led to a 40 percent increase in the consumption of fresh vegetables (Armstrong, 2000). Today, community gardens are still used to ensure that everyone has equitable access to fresh produce. One study revealed that households who did not participate in community gardens consumed fruits and vegetables 3.3 times per day (Alaimo, Packnett, Miles, & Kruger, 2008). In comparison, households with an individual involved in community gardens had a daily consumption rate of 4.4 (Alaimo et al., 2008).   

When community gardens are properly implemented and utilized, they can be an important source of empowerment for local citizens (Follmann & Viehoff, 2014). They can provide a space for productive work, interaction with each other, intercultural engagement and knowledge exchange (Follmann & Viehoff, 2014; Armstrong, 2000; Chan et al., 2015). Thus, they become a symbol of unity and increase neighborhood pride (Armstrong, 2000). This social capital is important to increase psychological support (Chan et al., 2015). As a result, community gardens have been established as a component of health promotion (Armstrong, 2000).

Policy Development and Citizen Engagement

Overall, the focus on community gardens is to foster a greater quality of life and community rather than consumption and individualism (Follmann & Viehoff, 2014). In order to continue to foster sustainable community gardens, policy development processes must be examined (Jermé & Wakefield, 2013). Local citizens must be able to participate in the development of policies, and the policies must ensure that citizens have access to gardens that are fairly allocated (Jermé & Wakefield, 2013). Success also depends on a collaborative approach between the various government agencies involved (Jermé & Wakefield, 2013).

 

References:

Alaimo, K., Packnett, E., Miles, R. a., & Kruger, D. J. (2008). Fruit and Vegetable Intake among Urban Community Gardeners. Journal of Nutrition Education and Behavior, 40(2), 94–101. doi:10.1016/j.jneb.2006.12.003

Armstrong, D. (2000). A survey of community gardens in upstate New York: Implications for health promotion and community development. Health & Place, 6(4), 319–327. doi:10.1016/S1353-8292(00)00013-7

Chan, J., DuBois, B., & Tidball, K. G. (2015). Refuges of local resilience: Community gardens in post-Sandy New York City. Urban Forestry and Urban Greening, 14(3), 625–635. doi:10.1016/j.ufug.2015.06.005

Follmann, A., & Viehoff, V. (2014). A green garden on red clay: creating a new urban common as a form of political gardening in Cologne, Germany. Local Environment, 20(10), 1148–1174. doi:10.1080/13549839.2014.894966

Jermé, E. S., & Wakefield, S. (2013). Growing a just garden: environmental justice and the development of a community garden policy for Hamilton, Ontario. Planning Theory & Practice, 14(3), 295–314. doi:10.1080/14649357.2013.812743

Government Policy, Infectious Diseases, Vaccination

HPV Vaccination in the Japanese MSM Community: A Call to Action

~Written by David Boedeker (Contact: dhboedeker@gmail.com; Twitter: @dhboedeker)

HPV vaccination has faced pushback from communities since its introduction in 2006. Perhaps the most shocking story comes from Japan. In 2010, the Japanese government began to give girls ages 12 to 16 the vaccine for free. The government recommended girls receive the vaccine[1], and vaccination rates climbed. However, all of that changed in 2013 when an anti-HPV vaccination movement successfully advocated that the government withdraw its recommendation. The aftermath has been dramatic: vaccination rates dropped from roughly 70% to 1%, leaving millions of adolescents unprotected from HPV-related cancers. Interestingly, this decision coincided with the United States moving to ramp up vaccination efforts. Moreover, the scientific data that prompted the Japanese government to withdraw its recommendation is based in theories that are not biologically possible, as one critic noted[2].

In response, many researchers and physicians are advocating for increased vaccination campaigns in Japan. Historically, these initiatives have focused on females since it has been established that HPV vaccination is important to prevent cervical cancer and other HPV-related cancers. However, it is increasingly recognized that HPV vaccination for males is also critical, especially to prevent throat cancers, which are expected to surpass cervical cancers as the most common HPV-related cancer by 2020.

HPV infection is not only related to throat and cervical cancers; it also increases the risk of developing mouth, tongue, and anal cancers. These are all cancers men can develop, and these are all cancers that Japanese men are currently at risk of developing because they are not vaccinated. Physicians, researchers, and government officials in Japan must expand vaccination efforts to include males, particularly the men who have sex with men (MSM).

MSMs are especially susceptible to anal cancer, a rare cancer, but one that disproportionately affects the LGBTQ+ community. Gay men are 20 times more likely to develop anal cancer compared to the general population, and HIV positive gay and bisexual men are 40 times more likely than the general population to develop this cancer[3].

Why must the Japanese government in particular take action? In Japan, same-sex behavior is stigmatized, which makes the LGBTQ+ community a hard-to-reach population [4] that may face challenges [5] when seeking healthcare services. These challenges may negatively impact the likelihood that they will receive the HPV vaccine. Also, the oncogenic (cancer-causing) HPV infection rate in the Japanese MSM community is 75.9%. Among MSMs who are HIV positive, the oncogenic HPV infection rate is 66% [6]. Most of these infections would have been preventable with administration of the HPV vaccine.

So, what can these government officials do? A driving force behind HPV vaccination is provider recommendation. Many patients state the reason they ultimately received the HPV vaccine is because their provider recommended it to them[7]. Some Japanese OB/GYNs are currently advocating that the government reinstate its HPV vaccination recommendation. A reinstatement might encourage more Japanese physicians to recommend the HPV vaccine, increasing the country’s vaccination rate and protecting its currently vulnerable population. However, it is important for these providers to advocate that the government not only recommend the vaccine to females, but to males as well. Moreover, this policy may benefit the MSM community by improving healthcare access and decreasing oncogenic HPV infection rates.

References:

[1] Hanley SJB, Yoshioka E, Ito Y, Kishi R. HPV vaccination crisis in Japan. The Lancet. 2015 June 27; 385(9987): 2571. DOI: http://dx.doi.org/10.1016/S0140-6736(15)61152-7

[2] The Public Hearing on Adverse Events following HPV vaccine in Japan [Internet]. Japan: Ministry of Health, Labour and Welfare; 2014 Feb [cited 2016 Sep 10]. Available from: http://www.mhlw.go.jp/stf/shingi/0000048229.html

[3] Margolies L, Goeren B. Anal cancer, HIV, and gay/bisexual men [Internet]. New York: Gay Men's Health Crisis; 2009 Sep [cited 2016 Sep 10]. Available from: http://www.gmhc.org/files/editor/file/ti_0909.pdf

[4] Nomura Y, Poudel KC, Jimba M. Hard-to-reach populations in Japan. Southeast Asian J Trop Med Public Health. 2007 Mar;38(2):325-7.

[5] Hidaka Y, Operario D, Tsuji H, et al. Prevalence of Sexual Victimization and Correlates of Forced Sex in Japanese Men Who Have Sex with Men. Stephenson R, ed. PLoS ONE. 2014;9(5):e95675. doi:10.1371/journal.pone.0095675.

[6] Nagata N, Watanabe K, Nishijima T, Tadokoro K, Watanabe K, Shimbo T, Niikura R, Sekine K, Akiyama J, Teruya K, Gatanaga H, Kikuchi Y, Uemura N, Oka S. Prevalence of Anal Human Papillomavirus Infection and Risk Factors among HIV-positive Patients in Tokyo, Japan. PLoS One. 2015;10(9):e0137434. doi: 10.1371/journal.pone.0137434. PMID: 26368294, PMCID: PMC4569050

[7] Hanley SJ, Yoshioka E, Ito Y, Konno R, Hayashi Y, et al. Acceptance of and attitudes towards human papillomavirus vaccination in Japanese mothers of adolescent girls. Vaccine. 2012 Aug 24;30(39):5740-7. PubMed PMID: 22796375.

Government Policy, Health Systems, Healthcare Workforce, International Aid, Non-Communicable Diseases, Organizations, Refugee Health

Refugee Health in Europe: Who is Responsible?

~Written by Victoria Stanford (Contact: vstanford@hotmail.co.uk)

Tents below a motorway pass, Piraeus Port, Greece. Photo credit: Victoria Stanford

 

The number of refugees arriving in Europe continues to rise, despite the EU-Turkey deal struck in March 2016 aimed at halting the numbers of new arrivals. This deal represented one of the first consensual decisions made by the 28 member states of how to respond to the unprecedented refugee crisis in Europe seen over recent years. However, across Europe there remains an overwhelming lack of political effectiveness, or indeed will, to co-ordinate the care of those arriving on the continent. Supranational institutions, European governance bodies, NGOs and humanitarian partners have scrambled in varying degrees of commitment to offer their services to refugees and the impression for many is that they are not achieving enough, quickly enough. But how have the various actors responded to the health needs of the refugees, and who is held accountable for this most basic human necessity?

Arrival versus Settlement

There is a significant difference between the immediate and long-term healthcare needs seen among refugee populations. This protracted crisis must be able to respond to both the immediate and often-life saving measures needed on Greek islands where refugees are still arriving by boat, and the long-term needs of refugees who have settled in host countries, in many cases for months or even years. Understanding this transition between the emergency and post-emergency phase, is essential for planning an effective healthcare response. The needs of those new arrivals mostly consists of sanitation, nutrition, shelter and basic safety provision, whilst those further along the asylum process must be integrated into long-term health systems that provide them with more complex and comprehensive services such as chronic disease management.

 As it stands, the initial needs of refugees arriving to European shores are often provided by humanitarian agencies who are equipped to launch an emergency response, and gradually they hand over this responsibility to the local health care structures. An excellent example of this was seen in Bulgaria when Doctors without Borders provided medical care to over 1500 refugees, allowing the national authorities who have now taken over healthcare service provision in this area, to build capacity and prepare (1). In many places this handover scenario has not been achieved so clearly and in fact often it is best for organisations and local partners to share the healthcare responsibilities. For example in Piraeus port in Athens (now dissolved), NGOs such as Praxis and the Red Cross were stationed within the camp itself and acted as primary care providers to the population on the ground, referring patients who required more specialised care on to state-run and funded hospitals or clinics in Athens. A similar system is currently established between the residents of the Jungle camp in Calais and the PASS clinic (Permanence d'Accès aux Soins de Santé)-provided by the government for refugees and others without social security insurance in France. However the extent to which this collaborative effort is effective depends much on the nature of the healthcare needs required; patients with mental health issues requiring long-term psychological treatment or those with post-surgery rehabilitation needs are often prematurely discharged or simply not offered longstanding care. Logistical difficulties are also often neglected as many appointments and consultations are arranged in neighbouring cities and patients are required to arrange their own transport which for many is an impossibility.  Achieving adequate provision and access in healthcare for refugees is complex and is largely dependent on context, their status in the asylum process and capacities of local health organisations.

The ‘Unofficial’ Refugee

Much complexity has been added to this crisis by the lack of clarity in defining those who are arriving in Europe- undocumented migrants, labour migrants, refugees and asylum seekers are terms often confused and used interchangeably and this has an impact on how these people can interact with official services. As refugees and others spread across Europe, the way in which they settle varies dramatically-there are families living in air-conditioned containers in official UN-led refugee camps, whilst others squat in abandoned buildings in the suburbs of Athens. This undoubtedly leads to much heterogeneity in terms of both their access to and quality of healthcare. Much of the healthcare that refugees living in official camps receive is provided by large, international NGOs such as Doctors without Borders (MSF) or the Red Cross. These organisations provide high-standard medical and nursing care, including psychological support in many cases, and also organise public health services such as child immunisations. As priority for official camp accommodation is usually given to families with children or vulnerable people with either chronic diseases or disabilities, providing comprehensive healthcare services to these populations is even more imperative. What this means however, is that resources are stretched thin and those refugees who are either in transit or living in unofficial areas often receive a lower quality or even a complete lack of healthcare.

The legal status of a refugee can also be a barrier to seeking healthcare, particularly in the few chaotic months after arrival in Europe. Many do not fully understand their legal rights or how to access healthcare in host countries; this is particularly problematic for those who are not settled immediately into official camps, instead attempting to cross international borders or avoid registration for fear of the barriers this may pose to freedom of movement (2). This means many do not receive their healthcare entitlements and depend on the ad-hoc and inconsistent presence of healthcare-providing groups often from outside any official aid delivery process.

The ‘unofficial’ refugee population is in fact where the grassroots organisations have trumped more established humanitarian groups. Countless groups have been set up in recent years by concerned citizens across Europe and have provided the in-the-field manpower that many official partners have failed to do. Groups such as Drop in the Ocean, Care 4 Calais, Help Refugees and many others have integrated into the ‘official’ aid delivery system and have in many cases outpaced those organisations who are often restricted by mandates or internal bureaucracy.  These groups offer assistance that is not always recorded on health surveillance statistics or official reports but in fact they are in many cases acting as primary carers. As healthcare itself is not the only way of keeping refugees healthy, these groups who attend to other needs such as shelter and food provision, hygiene, childcare and education may actually be having a significant impact on the refugee population’s health (3).

What about the Supranationals?

Red Cross Measles Vaccination Campaign, Scaramangas Camp, Athens. Photo credit: Victoria Stanford

Under the 1951 Refugee Convention, refugees should enjoy access to health services equivalent to the host population, and institutions such as the World Health Organisation (WHO) and the Office of the United Nations High Commissioner for Refugees (UNHCR) are tasked with upholding these rights under the UN Charter (4). It is increasingly clear that Europe is struggling to deal with the crisis and the UN has put pressure on European governance bodies to establish a comprehensive, mutually-agreed response plan to address the health needs of the refugee populations. This has achieved some success particularly in communicable disease control with large-scale vaccination programmes used in camps and non-camp settings alike (5) (see photo).

 However, the long-term nature of this crisis will require more of a focus on capacity-building of existing healthcare structures in host countries. For this reason, the WHO has performed a number of Assessment missions in countries receiving the most footfall of refugee movement including Cyprus, Greece, Italy and others, providing countries with context-specific information and guidance on responding to the health needs of refugees either temporarily or permanently settling in these countries (6). These analyses of the current preparedness of national health structures have helped to pinpoint where increased funding or skills are needed to boost local response; the European Commission have subsequently invested over 5 million euros on projects with the aim of “supporting member states under particular migratory pressure in their response to health-related challenges” (7). Crucially, these projects integrate NGOs with national structures, bridging the gap between short and long-term response, and focus on fostering comprehensive access to all aspects of the health system, not only emergency care. One of these projects also places a particular focus on the health needs of pregnant women, unaccompanied minors and young children, highlighting a concern for the most vulnerable populations in this crisis (7). However, whilst these projects are theoretical problem-solvers, there is a gap between plan and action. Many projects will take years to see results and whilst they do, countries such as Greece are reliant on existing health care systems, which have been struggling for years to cope with both the steady influx of refugees over many years and domestic austerity policies (8).

The bottom line is that funded and elected institutions such as the UN are mandated to protect the rights of refugees and these include access to healthcare. This situation sees the heavily bureaucratised system overloaded and rendered flimsy by the sheer volume of refugees depending on it, not only in Europe. This has meant that other humanitarian partners and grassroots movements have stepped in and provided invaluable assistance on the ground. The provision of healthcare to refugees in Europe largely depends on capacity and it is clear that there must be far-reaching plans made to build on both national and international health system structures. Whether these plans will materialise into effective action that both prevents ill health and treats disease remains to be seen as the crisis, without long-term solutions, inevitably continues. 

 

References:

(1)   MSF (2016) Bulgaria: providing healthcare to Syrian refugees [Online] Available at: http://www.msf.org.uk/article/bulgaria-providing-healthcare-syrian-refugees [Accessed August 2016)

(2)   Global Health Watch (2015) Migrants and asylum seekers; the healthcare sector, London, Page 63.

(3)   Kuepper, M (2016) Does Germany need to rethink its policies on refugees? Researchgate.net [Online] Available at: https://www.researchgate.net/blog/post/does-germany-need-to-rethink-its-policies-on-healthcare-for-refugees [Accessed August 2016]

(4)   UNHCR; Health (2016) [Online] Available at: http://www.unhcr.org/uk/health.html [Accessed August 2016]

(5)   UN News Centre (2015) UN seeks common European strategy on healthcare for refugee and migrant influx [Online] Available at: http://www.un.org/apps/news/story.asp?NewsID=52630#.V7DT6_krK01 [Accessed August 2016]

(6)   WHO (2015) Stepping up action on migrant and refugee health [Online] Available at: http://www.euro.who.int/en/countries/greece/news/news/2015/06/stepping-up-action-on-migrant-and-refugee-health [Accessed August 2016]

(7)   European Commission Health Programme (2015) Health projects to support member states, Geneva.

(8)   Chrisafis, A (2015) Greek debt crisis: of all the damage, healthcare has been hit the worst, The Guardian, 9 July 2015 [Online] Available at: https://www.theguardian.com/world/2015/jul/09/greek-debt-crisis-damage-healthcare-hospital-austerity [Accessed August 2016]

Climate Change, Health Promotion, Built Environment, Government Policy

Vulnerability of Urban Populations to Ambient Air Pollution

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

Dannenberg et al. 2011

Urban populations have always been exposed to ambient (outdoor) air pollution because urban regions have high-density industries and populations (Dannenberg et al., 2011). High levels of pollution result from the concentration of sources of combustion (Dannenberg et al., 2011). There are two types of pollutants: primary and secondary. Primary pollutants are those that are directly emitted (Dannenberg et al., 2011). These include sulfur dioxide, which is released from power plants, and carbon monoxide from fossil fuel combustion (Dannenberg et al., 2011). In contrast, secondary pollutants result from the physical and secondary conversion of other pollutants (Dannenberg et al., 2011). Tropospheric ozone is one example; it forms through the chemical reactions of anthropogenic and biogenic precursors (Dannenberg et al., 2011).

Both primary and secondary pollutants lead to negative health consequences, including eye irritation, fatigue, headaches and more severe effects such as bronchoconstriction, lung impairment and neurological damage (Dannenberg et al., 2011). Certain populations are particularly vulnerable to ambient air pollution. For example, as a result of physiological and psychological factors, children are more sensitive to ambient pollution (Vanos, 2015). Furthermore, those with less education and lower socio-economic status also face a greater risk of exposure to ambient air pollution; thus, highlighting pollution an issue of environmental justice as well (Dannenberg et al., 2011).

Since air pollution is multifaceted, it is not easy to determine a solution. More research is required, to determine the severity of ambient air pollutants in different regions and how different populations are impacted. Furthermore, it is important to develop and implement policies that will reduce the prevalence of ambient air pollutants and their health consequences. For example, in order to provide evidence-based advice on the impacts of air pollution on health, the WHO Regional Office for Europe developed two projects-the “Review of Evidence on Health Aspects of Air Pollution” (REVIHAAP) and the “Health Risks of Air Pollution in Europe” (HRAPIE), which were completed in 2013 (WHO, 2013). The findings from these projects guided changes in the EU air quality policies that were implemented that same year (WHO, 2013).

The built environment also plays an important role in mitigating air pollution. Regions should employ sustainable development practices to ensure energy-efficient land use and transportation systems to reduce emissions (Dora et al., 2015). Moreover, attention should be given to the proximity of homes and schools to sources of pollution (Dannenberg et al., 2011). Urban Structure Types (USTs) is one method that could be used, as it is a spatial indicator that describes urban regions through the assessment of land use, physical properties and environmental characteristics (Réquia Júnior et al., 2015). The UST method assesses the morphology of housing, green spaces and industrial buildings which can be compared, to assess the relationship with a health risk (Réquia Júnior et al., 2015).

Like other global health problems, air pollution is complex. It is not unique to one region because it reaches across borders. As a result, governments and organizations from various regions need to work together to mitigate this problem.

References:

Dannenberg, A. L., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places:

Designing and Building for Health, Well-Being, and Sustainability. Washington: Island Press.

Dora, C., Haines, A., Balbus, J., Fletcher, E., Adair-rohani, H., Alabaster, G., … Neira, M. (2015). Indicators linking health and sustainability in the post-2015. The Lancet, 385(9965), 380–391. doi:10.1016/S0140-6736(14)60605-X

Réquia Júnior, W. J., Roig, H. L., & Koutrakis, P. (2015). A novel land use approach for assessment of human health: The relationship between urban structure types and cardiorespiratory disease risk. Environment International, 85, 334–342. doi:10.1016/j.envint.2015.09.026

Vanos, J. K. (2015). Children’s health and vulnerability in outdoor microclimates: A comprehensive review. Environment International, 76, 1–15. doi:10.1016/j.envint.2014.11.016

World Health Organization. (2013). Health risks of air pollution in Europe-HRAPIE project

Infectious Diseases, Research, Vaccination, Health Systems, Government Policy

Defeating Tuberculosis: A Possibility?

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

Disease has always played a part in reforming community and geographical distribution of people through the ages. The bubonic plague, the Spanish flu, cholera and tuberculosis (TB), are some of the illnesses that have altered human history. Interestingly, TB has been glorified in literature more than others. The characters, Mimi in La boheme, Fantine in Les Miserables and Satine in Moulin Rouge all met with a similar fate at the hands of this disease.

According to the Global Tuberculosis Report 2015, the year 2015 is considered a turning point for TB as the global community progressed from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). TB mortality has decreased by 47% since 1990. Between 1990 and 2014, as a result of correct and timely diagnosis, 43 million lives were saved. We have made progress by moving from the “Stop TB Strategy” to the “End TB Strategy”. According to the latter, the targets for 2030 are to reduce the number of TB deaths by 90% and incidence by 80% (1).

Source: TBAlert.org

These statistics give us hope for a world without TB. But, having worked in a tertiary hospital in a low middle-income country, I have my doubts. Although the statistics reported by the World Health Organization (WHO) are the best available at the moment, these are estimates with very wide confidence intervals and may not provide a precise idea of the current situation in low and low middle income countries (LIC and LMICs).

In the surgical ward where I worked, one-third of the abdominal procedures were for perforation due to abdominal TB. To my knowledge, patient records were maintained through an electronic health system on the hospital server. Hard copies of the records were kept in nurses’ offices or junior doctors; duty rooms. These were put in storage, usually available for 4 to 5 years. The conditions of the storage area were extremely shabby and damp, where paper records could hardly survive. Electronic records, however, were said to be available in perpetuity. No one knew if these records were ever shared with the WHO to help with estimates. Popular opinion was that if the world knew the actual incidence and prevalence of diseases like TB in countries like ours it would be an embarrassment. Regardless, it is essential to have as accurate as possible estimates to converge efforts towards a TB free world.

Despite the best intentions and apparently achievable goals, the situation remains grim. According to the WHO, TB still imposes a great burden on the world. In 2014, 9.6 million new cases of TB were diagnosed while 1.5 million people died as a result of TB (2). Despite the history of this disease, research for newer TB drugs has been limited (3). In 2012, a new drug for multidrug resistant TB was introduced after a drought of 50 years (4). In addition, though BCG vaccines are part of immunization programs in countries where the disease is endemic, the current vaccine was developed in 1921 and is not entirely effective (5). A systemic review and meta-analysis that included articles from 1950 to 2013 reported 19% efficacy against TB in vaccinated children compared to non-vaccinated children (6). Although current research is encouraging there are questions of affordability of newer drugs for low resource countries where TB is more prevalent. Furthermore, five percent of the global burden of TB is due to multidrug resistant strains (7). The research required for averting these cases poses additional problems of affordability, availability and accessibility in LICs and LMICs.

Children present another area of grave concern. It is estimated that 550,000 children are infected with TB each year. The condition is frequently overlooked in children, often due to delayed and inefficient diagnosis (8). Adoption of the latest recommended diagnostic tools by the WHO is a challenge in itself because accessibility, affordability and availability again come into play in LICs and LMICs. Since TB flourishes in poor living conditions, the current global refugee and migrant situation has increased concerns about TB exposure, infection and transmission (9).

It is time that LICs and LMICs focus on establishing the true burden of major diseases like TB, and work towards adopting recommended diagnostic tools and treatment for all forms of TB. Unless the state actors and international community work together, the policies and aid provided will continue to fall short and the target to end TB will remain out of reach.

 

References:

1. World Health Organization. Global Tuberculosis Report 2015. 2015.

2. World Health Organization. Research for Tuberculosis Elimination. 2014.

3. Frick M. 2014. Report on Tuberculosis Research Funding Trends, 2005-2013. [Internet]. Treatment Action Group. 2015. Available from: http://www.treatmentactiongroup.org/sites/tagone.drupalgardens.com/files/tbrd2012 final.pdf

4. Médecins Sans Frontières, International Union Against Tuberculosis and Lung Disease. DR-TB Drugs Under the Microscope. Sources and prices for drug-resistant tuberculosis medicines. 2nd edition. 2013.

5. World Health Organization. Tuberculosis vaccine development [Internet]. World Health Organization; 2015 [cited 2016 Mar 19]. Available from: http://www.who.int/immunization/research/development/tuberculosis/en/

6. A Roy et al. Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systemic review and meta-analysis.  BMJ 2014; 349:g4643

7. World Health Organization. Multidrug Resistant Tuberculosis (MDR-TB). 2015.

8. World Health Organization. Combating Tuberculosis in Children. 2015.

9. World Health Organization. Tuberculosis prevention and care for migrants. 2014.

Government Policy, Inequality, Mental Health, Poverty

Uncovering the Realities of Human Trafficking

~Written by Sarah Weber (Contact: sarahkweber@gmail.com)

There is a hidden business of slavery that is tucked away from the untrained eye but alive and thriving today. The word "slavery" most likely conjures up images of African slaves in the United States (US) or Great Britain, a practice that was abolished in the nineteenth century. Although every country in the world now has laws banning slavery (the last being Mauritania in 2007), slavery still exists today in almost every country. Modern day slavery, also known as human trafficking, affects tens of millions of women, men and children around the world in the form of forced labor, domestic servitude, and sex trade [1]. In fact, there are more slaves now than at any other time in human history [1]. While the exact number of people trafficked globally is unknown, research efforts to better understand the magnitude of the issue have estimated that 21 to 36 million people are trafficked worldwide [1]. Human trafficking is the second largest criminal industry in the world after drug trafficking. Yet, the public is often not aware that it is such a significant global issue, affecting people not only in far away countries, but also in the countries, and possibly even the communities in which they reside.

What is human trafficking?

The terms “human trafficking,” “trafficking in persons,” and “modern day slavery” all refer to, "The act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts through the use of force, fraud, or coercion" [2]. A common definition was adopted by the United Nations (UN)'s Protocol to Prevent, Suppress and Punish Trafficking in Persons as:

"Trafficking in persons" shall mean the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power, or of a position of vulnerability, or of the giving or receiving of payments or benefits, to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation or the prostitution of others or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude or the removal of organs [3].

There are many different types of modern day slavery, including: debt bondage, contract slavery, sex trafficking, forced or servile marriage, domestic servitude, child labor and child soldiers.  According to Free the Slaves, a nonprofit focused on advocating against modern day slavery and liberating slaves, approximately 78% of slavery victims are in forced labor, 22% are in sex slavery, and 26% are children under age 18[1]. Learn more about the types of slavery and global statistics in this Free the Slaves factsheet here.

Source: freetheslaves.net

A key component of human trafficking is the use of force, fraud or coercion to lure victims into positions of exploitation. Traffickers generally prey on people who appear vulnerable, including those who are experiencing psychological or emotional vulnerability, economic hardship, lack of a social safety net, natural disasters or political instability. Women and girls who have been victims of sexual, physical or emotional abuse, and runaway children are particularly at risk. Refugees and/or people living in areas of war or political instability are also at increased risk [2].

Human Trafficking and Health

In addition to human trafficking blatantly violating human rights, it results in devastating long-lasting health consequences for the victims. Since victims are often dependent on their traffickers for their livelihood, receive limited food and are often malnourished. This is especially problematic for the estimated 5.5 million children in slavery today [4]. Women in forced prostitution and child soldiers, are often given drugs by their traffickers to ensure compliance, thus drug addiction is sadly all too common. Women forced into the sex industry are at risk of sexually transmitted infections and unwanted pregnancy and often don't have the agency to negotiate safer sex practices. [7]. In addition to the physical health effects, victims of human trafficking suffer from impaired emotional and psychological health [7]. Traffickers control through fear, physical, emotional and sexual assault, and manipulation [8]. This has negative impacts on victims and often leaves them ashamed, psychologically traumatized, emotionally attached, and afraid to leave their trafficker [8].

Raising Awareness Globally

Although human trafficking still does not receive an adequate amount of global attention or recognition, efforts in the last decade have elevated awareness of the problem. In 2010 the UN General Assembly adopted the Global Plan of Action to Combat Trafficking in Persons and urged countries to take coordinated efforts to combat and eliminate human trafficking [3]. In 2013 the UN General Assembly adopted a resolution, designating July 30 as the World Day against Trafficking in Persons. The resolution was made to, “Raise awareness of the situation of victims of human trafficking and for the promotion and protection of their rights” [5]. In December 2014, the president of the US, Barack Obama, established January as National Slavery and Human Trafficking Prevention Month in the US and January 11th as Human Trafficking Awareness Day, in recognition that modern day slavery or human trafficking still exists in communities across the US and the globe [6].

It is important to remember that human trafficking happens across the globe. It isn't something that just happens across international borders and/or in low- or middle-income countries. The US has an estimated 60,000 victims of slavery and the United Kingdom (UK) has an estimated 13,000 [1]. While a majority of these victims come from overseas, an alarming number of people are trafficked domestically within both the US and the UK, with the Federal Bureau of Investigation estimating that 293,000 American youth are at risk for sex trafficking within the US each year [9]. Given the rise of social media and the Internet, traffickers now use the Internet as a primary mechanism for recruiting victims both internationally and domestically.

Stopping Demand

Efforts to educate the public are an important step in combating the issue. Human trafficking is an industry because there is demand. Traffickers are motivated by high profits, with an estimated $150 billion USD generated by traffickers each year [1]. Therefore, decreasing/stopping the demand is key to eliminating human trafficking. "Sex tourism"- travel planned for the specific purpose of sex, generally to a country where prostitution is legal - fuels the demand for human trafficking, as does large events which bring in crowds of people [10]. In fact, the US Super Bowl is one of the largest magnets for sex trafficking globally [10]. Efforts to hold accountable both the traffickers and those purchasing the services are needed to stop the demand. Global efforts such as the UN's Protocol to Prevent, Suppress and Punish Trafficking in Persons, tougher sentencing for traffickers and purchasers in many countries, and local efforts to raise awareness in communities are helping to combat the issue. However, vigilance and awareness from all people and continued united global efforts are needed to end human trafficking.

References:

1. Free the Slaves. http://www.freetheslaves.net/about-slavery/  

2. United States Trafficking in Humans report, July 2015. http://www.state.gov/documents/organization/243557.pdf 

3. United Nations Office of Drugs and Crime. https://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html?ref=menuside

4. Anti-Slavery International. http://www.antislavery.org/english/slavery_today/child_slavery/default.aspx

5. United Nations World Day Against Human Trafficking in Persons. http://www.un.org/en/events/humantrafficking/

6. United States Department of Homeland Security. http://www.dhs.gov/blog/2015/01/20/national-slavery-and-human-trafficking-prevention-month

7. Center for Disease Control and Protection. http://wwwnc.cdc.gov/travel/page/sex-tourism

8. Polaris Project. https://polarisproject.org/victims-traffickers

9. Federal Bureau of Investigation, Law Enforcement Bulletin. https://leb.fbi.gov/2011/march/human-sex-trafficking

10. Federal Bureau of Investigation. https://www.fbi.gov/phoenix/press-releases/2015/super-bowl-sex-trafficking-operation 

Global Health Conferences, Government Policy, Healthcare Workforce, International Aid

Humanitarian Congress: A Workforce Self-Evaluates

~Written by Victoria Stanford (Contact: vstanford@hotmail.co.uk)

Humanitarian Congress, Berlin. Photo Credit: Victoria Stanford

The 17th Humanitarian Congress - ‘Understanding Failure, Adjusting Practice’ - took place in early October this year. The stimulating two-day event in Berlin, Germany could not have occurred at a more appropriate moment for the international humanitarian movement, its workers and its supporters. Just six days previously on October 3rd, an MSF (Doctors without Borders) trauma centre in Kunduz, Afghanistan was bombed, killing over 30 people including 10 patients and 13 staff, and injuring over 30 (more are missing and/or unidentifiable; MSF).  The Conference began with a poignant moment of silence for the victims of this tragedy. Inevitably however, the agenda was overwhelmingly full of lectures and seminars shedding light on numerous serious, devastating, and urgent crises that call upon the attention of the humanitarian community; the ongoing instability in the Central African Republic and protracted crisis in the Democratic Republic of Congo, the war in Syria and its subsequent refugee crisis, to name a few.

The demand on the humanitarian system is ever-growing and events such as the Congress facilitate a reflection of its principles, priorities, objectives and effectiveness. The focus on ‘failure’, albeit with its negative connotations, helpfully directed discussions towards ideas for improvement. Importantly, this approach avoided blame and finger-pointing and instead flagged problems that applied to many agencies, in many situations. For example, speakers from the Treatment Action Campaign suggested that international agencies often use local agencies as subcontractors, outsourcing risk to those whose protection is less internationally observed. It was argued that this can often mean that the local workforce, and those directly involved in the crisis are not placed at the centre of decision-making processes. Instead, beneficiaries or those workers who are part of the vulnerable community are treated as “victims” without autonomy, who blindly receive assistance rather than self-remediate. This idea of working with communities rather than for them, expanded to a conference-wide discussion of responsibility. Questions like, whose role is it to alleviate suffering, who should provide the funding and resources, and who should decide policy and provide care for vulnerable people in crisis situations were discussed.

 Whilst the conference facilitated stimulating intellectual discussion on the ideas and concepts of today’s humanitarianism, it also showed the reality of human need. An engineer from Syria who came to Germany as a refugee, risking his safety along the highly publicised journey across the Mediterranean, spoke about his experiences. He spoke of the boat that took him across the sea slowly sinking while other passengers panicked, treading water for hours until an eventual coastguard rescue. A story such as his reminded all at the Conference that the jargonised political discussions about the refugee crisis create a rhetoric that often overlooks the human experience. Speakers from the Democratic Republic of Congo and Somalia also provided the weekend’s event with a more individualised, personalised view of the concepts and themes we were discussing; reminding us of the human aspect of an increasingly intellectualised and politicised field. 

The Congress also served as a pre-dialogue to the Humanitarian Summit, a novel event announced by the UN Secretary-General to be held in Istanbul in early 2016. The purpose is to discuss current challenges and decide on an agenda for future humanitarian action (ICVA, 2015). Many of the regional consultations which will contribute to the Summit have already taken place, and many of the speakers in Berlin commented on the predictability of the points which have been brought up thus far. For example, it was mentioned by many that staff security and safety in the field is likely to ignite serious discussion and debate, as is the issue of agency co-ordination and leadership. The example of the Ebola Crisis in West Africa provided an astute example of this need for a decision on establishing leadership and accountability in humanitarian action; the general rhetoric was that the WHO did not do enough, early enough, and NGOs such as MSF found themselves to be the principal driving force behind the response efforts.  

Increasingly complex humanitarian crises which involve both more agencies and beneficiaries than ever before, must be met with an efficient workforce that can respond to the challenges the humanitarian sector faces. The Conference seemed to bring about an understanding of the fact that the extent to which the sector can be successful may depend on how far the actors are willing to innovate and adapt, introduce creativity, and collaborate with non-traditional allies.  Humanitarianism is no longer a subjective theory with ad-hoc projects run by the adventurous few, it is a rapidly-expanding multidisciplinary system which should be based on rigorous evidence and carried out by legitimate actors who show consistent adherence to mutual humanitarian principles. If and how this will come about will rely on the humanitarian sector continuing to self-evaluate, a feat which will be facilitated by the upcoming Summit in 2016, which we all eagerly anticipate.

References:

MSF (2015) Afghanistan: Death toll from the MSF hospital attack in Kunduz still rising, www.msf.org, 23rd October 2015 [Online] Available at: http://www.msf.org/article/aghanistan-death-toll-msf-hospital-attack-kunduz-still-rising [Accessed 24 October 2015]

ICVA (International Council of Voluntary Agencies) (2015) World Humanitarian Summit 2016 [Online] Available at: https://icvanetwork.org/world-humanitarian-summit-0 [Accessed 09 November 2015] 

Climate Change, Government Policy, Infectious Diseases, Water and Sanitation

Awaiting Death on a Heap Of Gold

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

In the far southeastern part of Pakistan lies an arid region with a gruesome past of disease and death. Despite this, it is considered a goldmine for black gold, establishing the Thar Desert as the 6th largest reserve of coal in the world. These reserves are estimated at 175 billion tonnes spanning over an area of 9000 sq. km enough to provide the country with energy for centuries to come. Perception about the treasure that lies beneath the scorching sand of Thar brings into question the existence of labour directed towards harnessing the gauged energy. It is exasperating to witness the indifference of the authorities to improving the conditions using its coal reserves, but the deaths of hundreds to date as a result of malnutrition in an area which has the potential to sustain itself and the rest of the country as well, is alarming. 

The current scenario of drought emerged in 2013 and continues to prevail beyond any hope of reprieve, natural or otherwise. But this is not the first time the region of Tharparkar has seen such unforgiving conditions. Thar experienced the worst drought in its history from 1998-2002, which affected 1.2 million people, killed 127 people and 60% of the population migrated to irrigated land. The streak of drought did not end completely, albeit lessened, for Thar experienced a moderate drought in 2004/2005. Yet another drought came along in 2009/2010 followed by one of the worst floods in Pakistan’s history.

Current statistics report worse figures than the drought of 1998-2002. Government officials have confirmed the deaths of 159 men, 168 women and 726 children under 5. Over 3000 cattle have been reported dead. The number of affected individuals is an estimated 1.1 million. 175,000 people are projected to have migrated. The numbers continue to rise as the government attempts to alleviate the situation. Locals however fear that the worst is yet to come. With inadequate rainfall to sustain the flora and fauna, and the ground water level sinking, the steps taken by the government fall short. Massive relief projects focused on purifying the saline water have been planned but despite 375 Reverse Osmosis pumps being installed, only a handful have been reported to be operational due to a lack of trained manpower. As a result, efforts made towards relief for this region have not affected the escalating numbers of lives being lost every day.

Besides the obvious malnutrition cases, another major complication is the rise in water borne diseases. These prove to be the largest contributors to mortality apart from birth asphyxia, pneumonia and sepsis. Thar has been attributed to have the highest under-five mortality rate in Pakistan with 90-100 deaths per 1000 live births. These statistics are distressing, however, doctors maintain that the figures have not changed in three decades, stressing the need for establishing a permanent solution for the region instead of episodic interest in chronic issues.

The need of the hour demands sustainable long-term development rather than multiple short bursts of temporary relief projects for an area that is recognised as prone to drought-like conditions.


Sources:

Latif A. Ray of light in Pakistan's drought-hit Thar desert (July 2015). BBC News Asia. Available at: http://www.bbc.com/news/world-asia-31851835

Hashim A. Pakistan's Thar residents living on the edge (March 2014). Aljazeera. Available at: http://www.aljazeera.com/indepth/features/2014/03/pakistan-thar-residents-living-edge-2014315121120904102.html

Climate Change, Poverty, Economic Burden, Economic Development, Government Policy

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).

"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


Children, Government Policy, Health Systems, Infectious Diseases, Vaccination, Poverty

Life after Polio: Towards Improving the Situation of Polio Survivors

~Written by Hussain Zandam (Contact: huzandam@gmail.com, twitter: @zandamatique)

 A woman paralyzed by polio, Rotary International (2010)

A woman paralyzed by polio, Rotary International (2010)

here is a surge of excitement among international development communities and global health partners as the World Health Organization announced that the battle against polio is gradually coming to an end (WHO, 2013). The Global Polio Eradication Initiative (GPEI) has set out a new strategy (Eradication and Endgame Strategic Plan), which hopefully will be the final onslaught that will result in a global certificate eradication of the disease by 2018 (GPEI, 2013). The eradication will be a significant victory for the global population, as future generations will also be saved from polio's devastating toll of death, morbidity, and disability.

 Map of the world comparing countries with polio cases in 1988 and 2014. Centers for Disease Control and Prevention, CDC (2014).

Map of the world comparing countries with polio cases in 1988 and 2014. Centers for Disease Control and Prevention, CDC (2014).

While a vast amount of resources has been disbursed to prevent polio since 1952, inadequate attention has been devoted to understanding the devastations left behind in the lives and households of polio survivors. The damage is more severe in those permanently disabled by the disease and those recently identified with post-polio syndrome (PPS). Post-polio syndrome is characterized by a renewal or new experience of polio symptoms including disability and functional deterioration after years of recovery and functional stability. PPS usually occurs 30-40 years after original infection and affects about 40% of polio survivors including those who developed permanent disability and those who recover from initial affectation with no or few symptoms (Lin and Lim, 2005). 

Although the situation of polio survivors in high-income countries is relatively well documented, there is a dearth of information in low and middle-income countries. This has profound political, economic and social implications for local, national and international policy-making. While the number of individuals disabled by polio will begin to disappear in the next few decades in the developed world, those in the developing world will continue to be a major concern for at least another generation (Gonzalez et al., 2010). And as the population of younger polio survivors reaches middle and old age, a new wave of individuals with PPS will begin to make additional demands on developing countries’ health systems.

Generally, individuals disabled through polio confront not only a range of physical disabilities but also significant social, financial and human rights barriers hindering integration and participation in families and communities. These barriers in turn, lead to chronic ill-health, social marginalization, limited access to education and employment, and high rates of poverty (Groce et al, 2011). Women are impacted disproportionately, as are individuals from poorer households, minority communities and from rural and urban slum areas (WHO/World Bank, 2011). 

To design effective programs and policies that improve life course outcomes for polio survivors, more research is essential. To begin, more accurate estimates of regional prevalence of polio survivors and the degree of residual disability sustained will be useful for efficient planning and appropriate resource allocation. In particular, addressing the stigma and prejudice encountered by persons disabled by polio must be part of long-term strategies to address the needs of people living with PPS and must be linked to broader efforts to confront disability and stigma faced by all people with disabilities. Ratification by countries of the Convention on the Rights of Persons with Disabilities (CRPD) and progressive national legislation are not enough - inclusion of polio survivors in community awareness campaigns and increased support by DPOs is also needed. And given the disproportionate impact of polio on women, DPOs must pay particular attention to gender sensitive research.

 

References:

Global Polio Eradication Initiative, 2013. Polio Eradication and Endgame Strategic Plan: 2013e2018.

Groce, N., Kett, M., Lang, R., Trani, J.F., 2011. Disability and poverty: the need for a more nuanced understanding of implications for development policy and practice. Third World Quarterly 32 (8), 1493e1513.

Gonzalez, H., Olsson, T., Borg, K., 2010. Management of postpolio syndrome. The Lancet Neurology 9 (6), 634e642.

Lin, K.H., Lim, Y.W., 2005. Post-poliomyelitis syndrome: case report and review of the literature. Annals-academy of MEDICINE SINGAPORE 34 (7), 447

WHO, 2013. Poliomyelitis. Fact Sheet No. 114. WHO, Geneva. http://www.who.int/ mediacentre/factsheets/fs114/en/index.html (accessed 11.08.15.).

WHO/World Bank, 2011. World Report on Disability. WHO, Geneva. http://www. who.int/disabilities/world_report/2011/en/index.html (accessed 12.08.15.).