Inequality

Water and Sanitation, Economic Burden, Inequality, Poverty

Water Risk Perception and the Use of Water Bottles

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

It is important to examine how social, organizational and cultural factors of the environment interact to influence health (Laverack, 2014). This has become increasingly evident as water quality and quantity is assessed to determine its impacts on the health of a community. As water is vital to human health, access to clean tap water is important; however, bottled water is often seen as a better alternative to tap water; especially in less developed regions. Many people in low-resources countries, such as Lebanon and Jordan, believe that bottled water is better than their tap water (Massoud, et al., 2013). However, the bottled water is not always effectively monitored for safety, and many are still at risk for various waterborne diseases. Thus, citizens face economic strain to pay for water that is perceived to, but may not be cleaner (Massoud et al., 2013).

Even when bottled water is cleaner than the local tap water, the poor are often unable to afford it, which further increases the gap between the different social classes (Massoud et al., 2013). Citizens should not have to pay for something that is a human right (Parag & Roberts, 2009). Encouraging the use of tap water pushes NGOs and government agencies to improve infrastructure that would make water available to all regardless of social class (Massoud et al., 2013)..

Although tap water in developed regions such as Canada is clean and reliable, bottled water is still popular as it is often purchased for convenience (Mikhailovich & Fitzgerald, 2014). Although the socio-economic implication of using plastic water bottles may not be as severe in such settings, there are still negative environmental consequences (Parag & Roberts, 2009). Manufacturing, packaging, transporting and disposing plastic water bottles is an inefficient use of resources and creates a large amount of waste (Parag & Roberts, 2009). This can have a negative impact on the ecosystem, as this waste can influence plants, animals, minerals and water (Parag & Roberts, 2009). As these systems interact with humans they eventually have a negative impact on the health of a population (Parag & Roberts, 2009). Thus, encouraging the use of re-usable water bottles encourages environmental awareness.

Nevertheless, non-reusable plastic water bottles have been beneficial for emergencies when clean water is not easily available (Canadian Bottled Water Association). With the gradual discontinuation of these bottles, alternative methods need to be determined to ensure that clean water is distributed during emergencies.

Overall, clean water is vital for human health, and easy accessibility is crucial. Thus, clean tap water must be made available and plastic bottles should be phased out in order to allow for greater use of re-usable bottles. This would be a lower burden on the environment, and decrease wealth inequality, consequently, having a positive impact on the health of citizens. 

References:

Laverack, G. (2014). A-Z of health promotion. UK: Palgrave Macmillan.

Massoud, M. a., Maroun, R., Abdelnabi, H., Jamali, I. I., & El-Fadel, M. (2013). Public perception and economic implications of bottled water consumption in underprivileged urban areas. Environmental Monitoring and Assessment, 185, 3093–3102. doi:10.1007/s10661-012-2775-x

Mikhailovich, K., & Fitzgerald, R. (2014). Community responses to the removal of bottled water on a university campus. International Journal of Sustainability in Higher Education, 15(3), 330–342. doi:10.1108/IJSHE-08-2012-0076

Parag, Y., & Roberts, J. T. (2009). A Battle Against the Bottles: Building, Claiming, and Regaining Tap-Water Trustworthiness. Society & Natural Resources, 22(7), 625–636. doi:10.1080/08941920802017248

 

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 

Economic Development, Government Policy, Inequality, International Aid, Political Instability, Poverty

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

"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.

Economic Burden, Economic Development, Government Policy, Health Insurance, Inequality, Poverty

Investing in Healthcare to Put a Dent in Poverty

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

 

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.


Inequality

Inequality within those who Call for it the Loudest

~Written by  Mikael Ashorn (Contact: mikael.ashorn@gmail.com)

Last March I had the chance to be part of a team representing our graduate program in the annual Emory Global Health Case Competition in Atlanta. We were given the not-so-easy task of transforming the World Health Organization (WHO) to the 21st century (http://www.globalhealth.emory.edu/what/student_programs/case_competitions/pdfs/2014_international_cc_case.pdf).

As we pondered this thrilling case among our group there was a lot of discussion around the fundamental core structure of the WHO and about the politics surrounding it. How could it serve better those in need – and as equally as possible? Among other things the WHO, as well as other United Nations (UN) branches, try to promote equity among the world's population. Health is listed as a fundamental human right, which everyone should have equal access to, already in the Universal Declaration of Human Rights in 1948. But do these large organizations promote equity also within their own system?

A Swiss newspaper writes (http://lenews.ch/2014/11/20/the-united-nations-more-consultants-fewer-rights/) on how the UN has started to save by using short-term consultants on a long-term basis. The Joint Inspection Unit (JIU) has already noted this negative trend. According to the JIU this trend creates inequality and a two-tier structure among the workers: consultants with next-to-none social benefits and full-time employees.

About half a year later I was attending Youth & Student UN-days in Finland. The theme was human rights. No one seemed to be talking about the equal rights of the employees within the UN. Among other presentations, I heard a former intern give a talk on how much she had learnt during her internship in the UN. However, in the same breath she spoke about how hard it was to make it through this unpaid internship financially.

Yes – you heard me right. Unpaid.

The UN does not pay any of its interns, nor does it help them financially in any other way. Does this provide equal opportunities for everyone to participate? Brilliant students from developing countries already struggle with tuition fees more than students coming from more prosperous countries. However in this field of work a good education is usually not sufficient to land a job. All employers expect work experience, which is usually gained through internships.

Some organizations, like the International Federation of Red Cross and Red Crescent Societies (IFRC), seem to have noticed this. For instance the IFRC claims to be “an equal opportunity employer”. With almost identical competences required as for internships for the UN, they pay all the interns expenses as well as a nominal salary.

A Washington Post article claims, that poor kids who do everything right are still worse off than rich kids who do everything wrong (http://www.washingtonpost.com/blogs/wonkblog/wp/2014/10/18/poor-kids-who-do-everything-right-dont-do-better-than-rich-kids-who-do-everything-wrong/). They claim that this is because of the different opportunities they get in life. These are the kinds of differences the UN promotes with non-paid internships. My fellows and I from developed countries are fortunate enough to have social-networks that we can rely on during the internship without a salary. However others are not so fortunate.

When the JIU published its report, the UN responded that changing the systems is very much in their interest, as they “need to have the best people possible”. By continuing these unpaid internships, the UN not only creates inequality between candidates but also might rule out some very competent prospective employees, whom are not fortunate enough to be able to work unpaid.

As an employer, the UN seems to pay rather high salaries (https://careers.un.org/lbw/home.aspx?viewtype=SAL). Could these be scaled back so that at the very least, interns' living expenses can be paid? This way, the UN would also be promoting equity within the organization. It would give more people the opportunity to get their careers kick-started through an internship, which future employers would appreciate.
 

Inequality, Poverty, Infectious Diseases

A Comprehensive Approach to HIV and Hepatitis C Interventions

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

One of the primary goals of public health, epidemiology, in particular, is estimating and examining the burden of disease. The burden in a population, however, is usually not just attributable to one illness or one causative agent. Many disease states carry with them the high likelihood of co-infections or opportunistic infections. Human immunodeficiency virus (HIV) and Hepatitis C (HCV) share at least one common route of transmission and often co-infect individuals. There are an estimated 40 million people worldwide who are infected with HIV and about 60-180 million globally are infected with HCV.1 Understanding the disease process as a whole means taking into consideration not only biological aspects of co-infection, but how this co-infection is propagated, or even mitigated, by patients’ behavior as well as their access to care. An all-inclusive and early detection approach to HIV-HCV treatment can help reduce the burden of disease in the affected population, and can help decrease transmission.

Effective interventions should focus on prevention, or at least early detection and treatment. This is not only good for the patient, but also for the health system. Between 2010 and 2019 it was estimated that HCV expenditures would be $10.7 billion.2 As disease progresses, costs increase (more medications, hospitalizations, etc.). Treatment should not only concentrate on drug therapy, but also address risk behaviors. Interventions, such as needle and syringe exchange programs (NSP) and opiate replacement therapy (ORT) are just some options that public health officials can use (and have used effectively) to curb HCV and HIV transmission in the community. Counseling is not a tool that should be overlooked as many of the co-infected population are affected with mental illness, a known risk factor for HIV acquisition. 

Both diseases separately represent a serious health concern, especially among injection drug using populations, but HIV-HCV co-infection introduces additional complications in treatment and disease progression of both conditions. Early interventions, especially during the acute phases of both diseases, can lead to better patient outcomes. Early treatment in co-infected individuals who have not yet been on antiretroviral therapy (ART) do better than those on existing ART regimens. The latter should be considered for treatment regimen changes to ensure minimal side effects and maximum adherence. Alcohol use in both HIV and HCV populations is a contributing factor to liver-related morbidity.3 Inclusion of alcohol and drug rehabilitation programs with drug therapy could decrease liver-related morbidity among co-infected patients. This is incredibly important because liver disease is the leading cause of mortality among co-infected individuals. 

Comprehensive interventions are useless if they cannot reach the population. Much has to be done to ensure that the delivery of these interventions captures as wide of an audience as possible. This includes having a well-trained staff of health workers and specialists who are able to support and motivate patients, convenient locations and times that are easily accessible for patients, and pricing should be affordable, if free is not an option.3 Many of the individuals taking advantage of such programs are often low-income, marginalized, and stigmatized by society. Giving these individuals the ability to take control of their condition and be aware of the risk behaviors and prevention strategies available for them could allow for better adherence to treatment, and consequently, better medical outcomes. Much like any other infectious disease that disproportionately affects low-income and vulnerable populations, the distribution and availability of resources are of utmost importance.

All of the above would be futile if there are no set standards to test and screen individuals who are most in need of these treatments. The lack of consensus among public health officials and the government regarding standardized screening among high-risk populations may contribute to the ongoing transmission of HIV and HCV, as well as co-infection. Ensuring sustainability of screening and treatment programs requires engagement and cooperation at all levels, from the patient to the care provider, to the community, to researchers, and even outward to national and international governing bodies.

1. Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006;44, Supplement 1(0): S6-S9.

2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health. 2000;90(10): 1562-

3. Viral Hepatitis: Hepatitis C Treatment. US Department of Veterans Affairs.  http://www.hepatitis.va.gov/provider/reviews/HCV-treatments.asp. Page updated December 9, 2013. Accessed October 21, 2014.

Poverty, Economic Development, Government Policy, Inequality, International Aid

Global Health and Post-2015 Agenda: Making a Case for Vulnerable Populations

~Written by Hussain Zandam, Health Systems and Policy Researcher (Contact: huzandam@gmail.com

The health-related Millennium Development Goals (MDGs) has made relative progress in improving access to essential healthcare. The next step, as suggested by many professionals in the development arena, is to consolidate on the gains and address the existing wide gap in quality healthcare among populations, especially in LMICs.  This can be tackled by addressing the challenges faced by a range of vulnerable populations. Vulnerable groups are defined as social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality. The group is represented by different categories of people including; women, children, elderly people, ethnic minorities, displaced people, people suffering from illnesses, people with disabilities and others. Together, these groups makes up a very significant population. For example, according to World Bank’s report on disability, PWDs makes up about 20% of world population equivalent to over billion people.

There is ample evidence confirming that access to effective health care is a major problem in the developing world. Many millions of people suffer and die from conditions for which there exist effective interventions. Vulnerable populations make up majority of these people. While some challenges are similar across different vulnerable people, others are specific to a particular vulnerable group. Selected factors to categorize groups should reflect specific subgroups of the population - such as poor rural women, or members of an ethnic minority - that require particular awareness due to their underlying social characteristics, which afford them less opportunity to be healthy than their more privileged counterparts. As a group, they also tend to be the least healthy and most probably have the most to benefit from health care. The fact that those most in need make least use of health care is widely considered inequitable.

Insufficient resources, inappropriate allocation, and inadequate quality are major impediments to the delivery of effective health care that reaches this group. The access problem cannot be solved without tackling each of these deficiencies. Even with limited resources, services should aim for equity, emphasizing the individual and their dignity rather than their merits, economic circumstances or ethnicity. Equitable access has been defined as ‘‘care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographical location and socio-economic status.  Adequate access is also linked to timeliness and the quality of services.

According to Organization for Economic Cooperation and Development/World Health Organization (OECD/WHO) DAC guidelines, the development of equitable financing through increasing pre-payment and risk pooling is one of four priorities for the development of a pro- poor health system delivering quality, accessible health services to the poor. The extension of health insurance cover is a long-term goal. At low levels of development, a more feasible policy is to maintain reliance on out-of-pocket payments but to grant exemptions to groups, principally the poor, for which price is a major deterrent to use. Policy initiatives can accelerate the process, however it is important for health policies to include not only commitments to core concepts of human rights ‘for all’, but also whether for vulnerable groups in a way which takes account of their ‘vulnerabilities’.

A general strategy can be defined at the global level, while policy measures should be heterogeneous, varying with the local conditions in which they are implemented. Finally, as nations and the entire world accept more and more responsibility for the health of human beings, the discussion on ‘‘universal health coverage’’ as the successor to health-related millennium development goals, global health should have a strong focus on the health of the poor and vulnerable.