Monthly Archives: January 2014

Medical-legal partnerships and the right to health

Just finished reading the fantastic article by Elizabeth Tobin Tyler on how we might start to conceptualize and advance a strategy for health as a human right in the United States. It made me realize just how weak our (in the U.S.) legal precedent and political appetite is for positive social and economic rights, including the right to health. The paper reinforced for me the history that the commitment to social and economic rights is, actually, deeply American, but was derailed by the politics of east-west / capitalist-communist posturing of the Cold War. It also gave me some hope that we may be able to begin to move away from a futile top-down, overly litigious, court-driven means of advancing the health as a human right agenda.

The idea advanced in this paper is centered around the potential power of linking health practitioners, lawyers, and community organizers: politicizing health care delivery and baking rights-based advocacy right in to the process of providing services:

“A systemic health and human rights strategy should be built upon interdisciplinary partnerships among health care providers, public health practitioners, lawyers, and community organizers. It should be founded on three principles: bearing witness to human rights violations within the community context; tracking systemic failures through data collection and monitoring; and broad-based legal strategies which include both individual and policy advocacy in a given community.”

Medical-legal partnerships are one way that this type of community-level partnership has been built between these different professional disciplines.

“The medical-legal partnership (MLP) movement in the US exemplifies a community-based health and human rights strategy that implements a legal advocacy and social accountability approach by connecting lawyers, health care providers, and public health practitioners. The MLP model, first established in a safety-net hospital pediatrics department in 1993, now exists in over 500 legal and medical institutions in the US. The model is also being adopted in both Australia and Canada.”

Clearly, MLPs should play a role in a rights-based advocacy strategy in the U.S. But, I wonder how this type of patient-provider-level accountability and advocacy could be used to politicize the act of global health delivery in low income countries? If the goal is to enable MOHs and governments to take on the responsibility for protecting the right to health of their citizens, don’t those citizens need mechanisms to hold those governments accountable for delivering on that duty?

It seems like a movement for the right to health requires both the “supply side” — creating the policy and financing space through foreign aid and “accompaniment” — and the “demand side” — legal recourse for those receiving substandard care or none at all.

Definitely some interesting stuff when considering a country like the U.S., which should have dealt with these issues long ago. But, for nations interested in building the systems of social protection and healthcare delivery to protect citizens’ right to health, ideas such as MLPs should be built in.

The evolution of global health education – Part III

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This post, by Tyler Boyd, is building off of his research on the evolution of global health education here and here.

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The first significant chunk of my research has been primarily focused on structured, academic programs in global health. While that work is ongoing, I have also begun to explore how student-led global health organizations on college campuses have grown and effected the growing field of global health education.

As a starting point, I opted to look at involvement with nationally affiliated global health organizations including: GlobeMed, Global Brigades, FACE AIDS, Student Global AIDS Campaign, The Foundation for International Medical Relief for Children, Manna Project International, Timmy Global Health, and Universities Allied for Essential Medicines. Based on these organizations’ websites, they have organized more than 300 chapters at colleges and universities in the US.

One of the first things that struck me was a high concentration of chapters within a few institutions. Duke and UNC Chapel hill between them boast 13 chapters, and the 8 schools with the most groups (about a third of a percent of all four year institutions) house 44 chapters or nearly 15% of all included nationally affiliated global health student organization chapters. In terms of the reach of these organizations, at least one of these national orgs is present at 178 colleges and universities. As a first step in visualizing this data, I graphed the geographic distribution of these chapters by state (Figure 1). Previously, I had posted a similar distribution for academic global health programs (Figure 2), and these two figures largely parallel one another in terms of the loci of global health engagement in universities.

Figure 1

Figure 2

However, while these graphs may provide some initial insights and demonstrate the strong presence of global health programs on the East Coast and in California/Washington, these areas also have many more academic institutions in general. In order to achieve a more proportionate perspective, I normalized the state distributions by comparing the number of global health academic programs or student groups to the total number of four year colleges and universities in each state (Figure 3). This visualization provides an interesting counterbalance to Figures 1 and 2. Here, states such as California, New York, and Illinois, all among the top 10 in number of global health programs, fall to near the bottom of the pack. Although the dramatic rise of outlier Rhode Island may reflect the state’s relatively few academic institutions, proportionally around a third of institutions in states like Colorado, Washington, and Arizona boast academic global health programs. The normalized data provides an interesting contrast, as some of these states may not come to mind as nexuses of global health education. Both methods certainly have limitations, but when viewed in concert, perhaps a snapshot of global health education may begin to emerge.

Figure 3

That’s not to say that the sheer number of programs, or their location, is the optimal or most important indicator of global health education. Instead, they are two of the easiest ways to quantify and begin to understand this complex and emerging field. To build off of this understanding, I am working to catalogue the establishment of each academic global health program and the total number of participants since its inception, constructing a timeline for the rise in university global health participation since the 1990s. Although I currently have this data for about half of the existing programs (Figures 4 and 5), the current data suggests a steady increase in the number of programs established. When complete, I hope this timeline will prove another foundational pillar for understanding the short legacy of global health education.

Figure 4

Figure 5

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By Tyler Boyd

Tyler is a biochemistry and American studies double major at Middlebury College in Vermont. Hailing from outside Chicago, he enjoys graphic design and is interested in travel and global health. He is excited to be working on this project this month and into the future.

Advancing the case for investing in health

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A nice piece was published this week in the Huffington Post summarizing the conclusions of the Global Health 2035 commission. Larry Summers and Gavin Yamey write that, “We are on the cusp of a once in human history achievement.” Major claims that seem hyperbolic until you dig into the report, as I did here. The report is significant because it brings together modern health and development economics and new methods to analyze what value could be created by building policies that consider health a public good and protect the health of the poor and marginalized in particular. From the HuffPo piece:

“Perhaps the most striking finding of The Lancet report is that the economic payoff from investing in a grand convergence would be enormous. We used new research methods from health economics to put a dollar amount on the direct value of greater survival. We found that every one dollar invested in achieving the grand convergence over the period 2015-2035 would return between 9 and 20 dollars. This return on investment is nothing short of astonishing. In financial markets, investments with foreseeable returns of between 9 to 1 and 20 to 1 over reasonable time horizons simply do not exist.”

But, of course, this achievement will take significant investment, much coming in the form of development assistance and foreign aid.

“Though low-income countries will still need direct financial support, we should begin to shift global health aid to providing global public goods. We must double our investment in research and development for vaccines, diagnostics and drugs for those conditions causing the most deaths in the poor world. We must invest more heavily in what is called “implementation science”–the identification of the most cost effective modes of treatment in different kinds of environments. And we must start to get serious about tackling cross-border threats, like antibiotic resistance, counterfeit medicines, and flu pandemics. The next flu pandemic could be far deadlier than the 1918 epidemic that killed 50 million people in an era before mass, international transit.”

The Global Health 2035 commission is coming on the heels of the expiration of the Millennium Development Goals and there seems to be a growing alignment of people in power – from Jim Kim to Bill Gates – that investment in public health is one of the best ways to view foreign aid in the coming decades.

“Something like a movement”

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Dr. Sriram Shamasunder has a beautiful and moving short essay about his time working at the PIH supported hospital in St. Marc, Haiti. A great quote:

International Solidarity: Nothing beautiful and lasting can be done alone. It also cannot be done immediately at scale nor should it. We need human relationships, built over time to transform systems. In global health the people we are trying to serve are by definition poor and sick. They are not the best constituency to organize themselves. This leads to policies and programs that don’t really have the people we serve at the table. I recently saw the film “Dallas Buyers Club” about the early days of HIV. Matthew McConaughey plays Ron Woodroof, a cowboy who contracts AIDS in an era where the FDA had not yet approved any medication. He goes on a personal mission to travel around the world and gain access to medications in the early 1980s. He is fearless, aggressive, and does not yield to the medical establishment. The story of the HIV movement has been told so many times, in so many elegant ways. Almost all versions detail how the afflicted pushed the establishment. Populations most devastated raised their collective voice and pushed. They had some political power because many were White or middle class. When they gained access, they aligned themselves with other HIV patients around the planet. Of course this is a simplified version of the story, but it illustrates to some degree what is happening in the immigration reform movement in the United States. Think tanks, policy advocates, academic scholars, and NGOs are certainly shaping the conversation. But the most compelling immigrant rights advocates I have witnessed are the “DREAMers” – the undocumented youth who came here when they were very young through no decision of their own. Like the protagonist in Dallas Buyers Club, the DREAMers are fearless and have the most to gain or lose. Their fight is intimate, personal and profound in a way that a Global Health movement confined to the walls of academia, or halls of the Gates foundation, or board rooms of the World Bank can never be. Those of us who are front-line workers but straddle the globe and work closely with our colleagues from Haiti to Liberia who have dedicated their lives to healing poor, sick patients and poor, sick systems would do well to imbibe their stories and tell them again and again and make sure they have the space to tell their story themselves. It is a small piece of having the most afflicted and the most poor at the table in a Global Health context that is almost inherently hierarchical, exclusionary, and fragmented.

Whatever this movement is, we need to continue to find ways of collapsing the enormous chasms of inequality and geography that currently exist between those bearing the brunt of ill health and disease and those working to create policies and systems to protect rights.

Haiti’s first Cardinal: A movement towards O for the P

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Here is something interesting: Pope Fancis recently appointed the first ever Haitian Cardinal during the appointment of new Cardinals which occurred on January 12th, the fourth anniversary of the devastating earthquake in Haiti. His name is Bishop Chibly Langlois of Les Cayes, Haiti.

“The appointment this January 12, 2014 will help focus attention on Haiti, especially on our Roman Catholic Church in Haiti, where the realities, the needs and the challenges will be brought up to a much higher level,” Cardinal-designate Langlois said in statements to Alter Presse.

Some analysts suggested that the Pope’s decision to announce the cardinal appointments on the four-year anniversary of the earthquake may have been a sign of special consideration for the devastated country.

The 2010 earthquake killed more than 200,000 people in Haiti and left more than 1 million homeless. It destroyed dozens of churches, including the archdiocesan seminary. Archbishop Serge Miot of Port-au-Prince also perished in the quake.

As president of the Haitian bishops, Cardinal-designate Langlois has worked in recovery efforts. He has also led the Church’s mediation efforts in talks between Haitian President Michel Martelly, the opposition and the parliament, in order to help carve out a path towards rebuilding the country.

First, I had no idea that Haiti had never had representation in the College of Cardinals. So, this is a big deal for Haiti, and the Catholic Church in that regard alone. But, it turns out that Haiti is not alone and Pope Francis is appointing Cardinals from poor countries around the world — from Asia, Latin America, the Carribean, and Africa — bucking the historical trend of Cardinals hailing almost exclusively from Europe and North America.

Why does this matter?

Well, it’s important to reflect on this as a matter of theology, and Pope Francis’ alignment with Liberation Theology, as demonstrated in his first Apostolic Exhortation which dismisses trickle down economics and the continual growth in economic inequality. Pope Francis recently met with one of the founding Fathers of Liberation Theology, Fr. Gustavo Gutierrez, a landmark for a theology that has at times been at odds with the Vatican. Making a preferential option for the poor certainly means bringing those who have been marginalized or excluded to the decision making table.

Second, this has the potential to have significant implications for those concerned about global health equity and our ability to bring millions of more people into the fight for health as a human right. From the same article in the New Catholic Reporter, Paul Farmer links these developments to the movement towards a focus on a preferential option for the poor:

Farmer, who is Catholic and says liberation theology inspired him, said he hopes that Francis’ meeting with Gutiérrez does mean an easing in the Vatican’s stance toward liberation theology, because that would allow the theology to spread more widely.

In particular, he said, he hopes that agencies, nonprofit groups, and governments that provide assistance to the world’s most impoverished people would adopt Gutiérrez’s ideas about a “preferential option for the poor” and his work on issues of structural violence.

Those groups “need this kind of inspiration,” Farmer told NCR.

“They need to understand that it’s wrong not to use these ideas,” he said. “That if you don’t understand structural violence, for example, you’re grasping around in the dark in public health, public education [and] poverty reduction. These ideas really warrant not just rehabilitation but widespread dissemination.”

All of this is amazing to think about: we now have the President of the World Bank, The Pope, and the President of the United States all expressing serious concern with inequality and the social problems it creates. This seems like a major moment of political opportunity. Will we be able to mobilize the grassroots pressure to capture this growing political opportunity and demand that real programs, policies, and systems be put in place to protect the poor and marginalized?

Just in: Jim Kim believes in the human right to health

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At that conference in DC hosted by The Center for Strategic and International Studies that I mentioned previously on this blog, Jim Kim, the President of the World Bank Group announced that he believes that “Health care is a right for everyone, in every country, rich or poor,” Kim said in remarks today at the event in Washington. “Not providing health, education, and social protection is fundamentally unjust — in addition to being a bad economic and political strategy.”

Not surprising at all from one of the founders of Partners In Health, but fantastic that he can make these pronouncements when sitting in his role as President of the World Bank, and while working to orient the bank to focus more on enabling poor countries to push for universal health coverage.

I’ll be posting more coverage from the “Universal Health Coverage in Emerging Economies” conference soon.

The evolution of global health education – Part II

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On to my second post and now midway through my second week in the PIH office, it seems we have just begun to scratch the surface of the vast, rather chaotic and disjointed wealth of information regarding global health education programs. Using the CUGH database as a foundation, our first goal is to chronicle the growth of global health education by pinpointing when each program in the database was established. Since this data has never been compiled, I had rather few tools at my disposal. After digging through several hundred university websites and launching a volley of emails, I have slowly started adding to the database.

In the meantime, I have also played around with the existing database, looking at the distribution of global health education (both geographically and by type of degree). Although these visualizations don’t reveal any earth-shattering conclusions, they do suggest some interesting preliminary trends.

Figure 1 breaks down global health education by type of degree, illustrating the heavy concentration of global health degrees, certificates, etc. at the graduate and professional level (while a rather anemic 41/207 programs at the undergraduate level). However, many leaders in the field of global health have pointed to the undergraduate level as the crucial locus for global health education. This is due, in part, to the inherent interdisciplinary nature of global health, which undergraduate programs are ideally situated to address. Perhaps, looking forward, a greater emphasis on undergraduate global health education must emerge.

Figure 2 points to a heavy concentration of global health programs on the East Coast and California. Containing many of the nation’s more prestigious, well funded academic institutions, it seems they may have played an integral role in establishing the legitimacy global health education (more to come on that later). Like I said, nothing too mind-blowing, but certainly a start as we find the direction we want to take this work.

Figure 1:

N=207
Graduate Degrees: MA, MS in Global Health
Graduate Academic Track: Certificate in Global Health within various degrees, PhD
Professional Track: Concentration or Certificate in Global Health within MD, residency, MPH, MSN
Undergraduate Track: minor, concentration, focus, track, or certificate in Global Health within various majors
Undergraduate Degree: BA in global health

Figure 2:

N=207

The data used for Figure 1 and Figure 2 is from the 2013 CUGH Global Health Programs Database. According to their website, the data contains information current as of February 2013. All information was drawn directly from the program websites, and may not be comprehensive. The database only contains programs that have an explicitly stated “global health” focus either within the degree title or as a track title within the degree. “International health” programs were not included.

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By Tyler Boyd

PIH | Engage: An Experiment

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I first heard of PIH | Engage from a listserv email, sent out to alumni of the study abroad program I participated in. Not knowing quite what to think, but already in love with the global health nonprofit Partners In Health, I emailed this mysterious Jon Shaffer with a few questions. Instead of the standard written reply sent a few days later, and in what I would come to know as typical Jon fashion, he immediately responded with “wanna hop on the phone?”

And so started my plunge into community organizing. As I would soon find out, PIH | Engage was a completely new initiative of Partners In Health, looking to build communities of volunteer organizers across the United States. These teams of 10 or so people would work to 1. Raise funds for the lifesaving work of Partners In Health, 2. Advocate for policies that enable governments to build functioning health systems, and 3. Create a space for discussion of the global health issues marginalized populations face every day. Jon would sometimes refer to PIH | Engage as an “experiment,” aimed at harnessing the inspirational power of PIH’s brand and engaging dedicated supporters in the movement for global health equity. With the recent explosion of global health departments and student groups on university campuses, the biggest engagement gap seemed to be for recent graduates, who may have studied these issues in college but found it too difficult to find well-paying jobs in global health after graduating.

For me, a passionate supporter of PIH’s work and a public health student/soon-to-be young professional with limited opportunities for direct involvement in global health work, PIH | Engage seemed perfect. I applied to be a Community Coordinator.

Like all fledgling community organizing initiatives, PIH | Engage’s pilot year had its ups and downs. Movement-building is hard work, I found, and takes serious commitment. But I ended the year excited and hopeful for the initiative’s future—already, communities (including my own) had been built across the U.S., and PIH | Engage had brought together more than one hundred dedicated volunteers. After graduation, I was determined to stay involved with this experiment that I had come to truly believe in. After a summer spent volunteering at the PIH Boston office, I jumped at the opportunity to apply as the Community Organizing Assistant and work to build PIH | Engage full time.

An illustration of PIH | Engage’s growth: Year 1 Training Institute, in the conference room of PIH & Year 2 Training Institute, with more than 60 Community Coordinators, coaches, and volunteers.

fundraising

Now, a few months later, PIH | Engage has made tremendous progress. We have about 40 strong communities and more than 300 members, who together have raised close to $40,000, advocated for continued U.S. support of the Global Fund, and began the “PIH | Educate” curriculum based on Dr. Paul Farmer et. al.’s excellent new textbook, Reimagining Global Health. Each month, I’m on the phone with each Community Coordinator, sharing best practices, discussing struggles, and coaching them through the campaign.

I recently undertook a thorough assessment to more systematically calculate each community’s “strength,” based on a series of metrics such as the size of their leadership teams, participation in the campaign, and events held. The results of this report were promising:

69% of communities ranked in the “superstar,” “great,” or “good” category for strength
88% of communities have held a first monthly meeting; 79% have held several meetings
67% have held their first event
Leadership teams have an average of 6 members, and 74% participated in the personal fundraising campaign

Through this analysis, I was able to see more clearly what structural elements of a community led to it’s success and what barriers most often caused a community to struggle. Jon and I will use this report to target our coaching and support of PIH | Engage teams in the coming months, and reflect on ways we can better recruit and plan for next year, Year 3 of PIH | Engage. As the first step, we hosted a Midpoint Review video-conferencing webinar with our entire network last week, to reflect on our progress so far and re-launch into our spring campaign.

As much as PIH | Engage is an experiment in community organizing, my journey from Community Coordinator to Community Organizing Assistant has been a wonderful and rewarding career experiment. It’s been incredible to be a part of this initiative, and see our movement grow. I can’t wait to continue to share our progress, successes, and challenges. Onward!

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By Sheena Wood

Sheena works as the Community Organizing Assistant at Partners In Health. A recent graduate from Brown University, she enjoys reading about community organizing and global health, traveling, and eating dark chocolate.

Health as development?

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The Guardian has a good article which makes the critical point that the vast majority of foreign aid flowing into Haiti since the devastating earthquake in Haiti (the fourth anniversary is this Sunday) has been directed almost exclusively to private, U.S.-based corporate development contractors.

See the data and the graph:

Haiti, in particular, ranks among the lowest in the percentage of USAID funding going to locally based NGOs or the Haitian government:

USAID claims that most Haitian NGOs and the government do not have sufficient internal financial controls to receive these contracts. They also cite that these data do not accurately account for less formal support to local organizations via subcontracting and local partnership and interactions. It is, however, impossible to know since the data on those subcontracts has yet to be published.

Despite a desire to reform from USAID administrator Rajiv Shah, major lobbying and entrenched interests exist to block reform.

Partners In Health, of course, is working to do things differently. Interested primarily in how we can best invest resources to build systems that can protect the human right to health, we know how vital it is to strengthen Haitian – particularly public – institutions. This has been the approach and rationale behind the major investment in the construction and operation of the University Hospital in Mirebalais, Haiti. Co-operated by the Haitian ministry of health and PIH, the hope is that through accompaniment, we can work to strengthen the capacity of the public institutions necessary for fulfillment of the right to health for Haitian citizens.

Beyond the rights-base requirement for the primacy of local, public institutions, the strategy also makes strong economic sense. New analysis by PIH and partners show that investment in health systems and necessary infrastructure like hospitals, can have a major economic multiplier in growing the Haitian economy. Using an input-output matrix, a well documented economic analytical tool, the team determined that for every $1.00 invested in the construction and operation of the University Hospital in Mirebalais, $1.82 was generated in revenue across many economic sectors in Haiti.

These results are entirely consistent with the case laid out by the Global Health 2035 Commission regarding the economic gains to be made by sound investments in health care delivery. As the movement lines up behind UHC as a major focus for the post-2015 global development goals, perhaps more evidence like this will help us move beyond the primarily self-serving orientation of foreign aid and development assistance as reported by The Guardian.

A Critical Engagement

A dialogue on advancing justice in health