Why women's health matters

Today marks the 100th anniversary of International Women's Day. Yet even as the world celebrates women everywhere, and the UN launches a special agency called UN Women to improve the lives of women worldwide, the USA seems to be paying mere lip-service to the idea.

The Republican majority of the U.S. House of Representatives has just voted to slash the budget for domestic and international programmes on family planning and reproductive health, including eliminating funding for the UNFPA (the UN Population Fund). This means that impoverished women in more than 150 countries will struggle to get any kind of help with contraception, maternal healthcare, or education.

This right-wing, abstinence-only, anti-abortion view of reproductive health is one that UNFPA suffered tremendously from during the Bush administration, and its budget was drastically cut. Obama coming to power seemed to herald a new era as he reinstated the organisation's funding to the tune of US$50 million. The outcome of this tussle over how to deal with reproductive health will have enormous implications for women worldwide.

Right now, the UNFPA is especially concerned about the health of adolescent women. These girls, hovering on the brink of adulthood, are extremely vulnerable. Many are forced into early marriage, during which they often suffer domestic violence and have babies well before they are physically ready. About 50 million girls under 18 are thought to be already married, and in the next decade it is estimated that 100 million more girls will marry before they turn 18.

Girls who marry during childhood tend not to go to school either, and the lack of education severely hampers any social development and robs them of economic autonomy. To document the grim reality of early marriage, and offer a glimpse into the life of a child bride, photographer Stephanie Sinclair is showing a series of photographs at the VII Gallery in Brooklyn, New York, until April 15. The images are also online here.

Photo credit: Stephanie Sinclair/VII

It's a miracle: the Vatican accepts that condoms stop HIV

The Vatican is set to host an HIV prevention conference on May 28, during which it will clarify its position on condom use to prevent the spread of the virus.

The catholic church's stance on the morality of health issues, especially when it comes to diseases like HIV/AIDS has always been significant, even if some scientists would prefer to ignore it, because of the large catholic populations in countries in Africa where HIV is so prevalent.

A focus on abstinence rather than contraception has in the past also heavily influenced US aid programmes for HIV. In an interview last year that was received with great excitement by UNAIDS, HIV activists and scientists, Pope Benedict XVI said that condom use by prostitutes could be seen as the "first step to moralisation", and that using a condom to prevent HIV transmission was a lesser evil than using contraception.

The Vatican is also about to update its 2008 guidelines on bioethics issues in stem cell research and reproductive technology, but whether those will be as pragmatic as the new stance on condom use remains to be seen.

The last edict had wordy explanations on the Church's position, but all it really came down to was a ban on any such technology. IVF? No. The morning-after pill? No. Gene therapy? No. The 2011 update has allegedly been sparked by a slipping of Catholic standards in hospitals.

In December 2010, an Arizona hospital had its "Catholic" status revoked because it chose to abort a baby to save the pregnant mother's life. The hospital says it is disappointed by the Church's decision but remains steadfast that it took the correct path.

In a press release, the hospital said: "Consistent with our values of dignity and justice, if we are presented with a situation in which a pregnancy threatens a woman’s life, our first priority is to save both patients. If that is not possible we will always save the life we can save".

Photo credit: loveleft/flickr

Plumbers without borders

When a disaster strikes, aid agencies tend to focus on food, shelter and healthcare. Water and sanitation is often neglected, even though the lack of clean water and decent sewage systems can wreak havoc on healthcare. In Haiti, for instance, cholera has now become the overwhelming health problem, and 3000 people are estimated to have died from a disease that is entirely treatable.

Now, the disease has spilled over into the neighbouring Dominican Republic, and this week, three cases were reported in New York (people who had attended a wedding in the Dominican Republic).

But public health experts predicted months ago that when basic infrastructure breaks down as spectacularly as it did after the earthquake a year ago, outbreaks of waterborne diseases like cholera are inevitable. Given this knowledge, how did cholera run riot?

One Haitian blogger points to the utter failure of the Haitian government to provide its people with clean water long before the earthquake hit:

"Instead of policies or plans to invest in water treatment facilities, we have been witnessing an erosion of the few water pipes we had in the capital and the other major metropolitan areas. There is not a single waste management facility in Haiti. Overall, the politics of water in Haiti has been a complete failure, and today we are paying a dear price for it."

Recently, aid agency Médecins Sans Frontières (Doctors Without Borders) made a scathing attack on the humanitarian aid response to Haiti. MSF's international president Unni Karunakara wrote in an opinion piece that agencies given funds to provide chlorinated water and improve sanitation took little action for months, which contributed enormously to the rapid spread of cholera after the initial outbreak.

Karunakara is particularly suspicious of the trend to cluster the provision of aid. In theory, this should harmonise the provision of similar types of aid. In reality, he says, it seems to mean awkwardly forcing together organisations of differing capabilities and experience.

"Instead of providing the technical support that many NGOs could benefit from," he says, "these clusters, at best, seem capable of only passing basic information and delivering few concrete results during a fast-moving emergency."

This urgently required technical knowledge could come from a new grassroots organisation called Plumbers Without Borders. The organisation, which is currently looking for expert plumbers, engineers, electricians, and carpenters, aims to provide the know-how for agencies that are trying to respond to emergencies in water and sanitation.

Should Bill Gates call the shots with polio?

Bill Gates is waging war with polio. The world has been on the verge of eradicating it for years, but stubborn pockets of disease remain in countries like India and Nigeria. Gates is now putting the might of his foundation behind eradication and is calling on governments and scientists to join him.

This latest move that has drawn fierce criticism from leading global health experts, including Donald A Henderson, the lynchpin in the smallpox eradication campaigns. The editor of The Lancet, Richard Horton, recently tweeted that global health does not depend on polio eradication.

The Gates Foundation has stirred controversy over disease eradication before. In 2007, it took the global health community by surprise when it announced a drive to eradicate malaria. Then too, malaria experts were concerned that it would divert from urgent research to control the disease through drugs and vaccines, and the jury still seems to be out on whether pushing for eradication is sensible.

Those who support Gates' polio plan argue that while eradication is more complex than it was for smallpox, aiming high can't hurt. The problem is that any move Gates makes is significant. Where Bill Gates go, the rest of global health follows. Arguably this then means that his foundation cannot ignore the judgement of the scientific community.

It is worrying then that in an article in the New York Times, Ezekiel J. Emanuel, chief bioethicist for the US National Institutes of Health says that since he had not seen enough data to form an opinion, he deferred "to people who’ve really studied the issue, like Bill Gates.”

Surely the balance has tipped the wrong way if a key figure in one of the world's most important health institutions, and who is said to be highly influential in the Obama administration, is looking to a philanthropist for advice on public health?

India slammed for jailing health activist

Just two weeks after Human Rights Day on December 10, the Indian government has sentenced a leading health and human rights activist to life in jail amidst fierce protest from noted academics and health professionals. Binayak Sen, an Indian public health expert and pro-poor advocate, was jailed last week after being accused of helping Maoist rebels.

Human rights groups such as Amnesty International say that the Indian government has unjustly sentenced Sen to an extraordinarily harsh and undeserved life sentence on the basis of dubious evidence. India has openly declared that left-wing ideologies are a threat to its economic growth - which it continues to pursue as aggressively as ever - and Sen's supporters say that in its desperate bid to quash growing Maoist insurgency, India is also ignoring basic human rights.

Sen has been globally lauded for his work to improve rural healthcare in India, and was awarded the 2008 Jonathan Mann award for Global Health and Human Rights. Respected intellectuals such as Amartya Sen and Noam Chomsky have petitioned against his life sentence.

Sen's various imprisonments (in 2007 too, he was held without trial for several months) expose serious weaknesses in India's judicial and political system. The government is growing politically more conservative while paradoxically trying to push for a more open and liberal economy. Yet Sen's jailing is also disastrous news for the country's public health. Sen has for decades fought for the health of marginalised people, such as India's vast and neglected tribal populations, which the government has virtually ignored.

Government schemes to improve healthcare in rural areas often fail through a lack of resources and corruption. For instance, a policy advisor at one of India's major health institutes told me that doctors who are recruited to work in remote villages often bribe a local to fake records for them while they themselves remain in the city. Thus, on paper it looks as though these populations are receiving healthcare when in fact, they never even see a doctor.

It is this broken health system that health professionals like Sen are struggling against. For India to jail one its few true champions of the poor is nothing short of a travesty.

How to fix mental health in poor countries

In developing countries, depression and anxiety are widespread, but the requisite healthcare to treat them rarely is. There are several reasons why mental health is woefully neglected in poor countries.

Often, such illnesses are harder to identify. Doctors and nurses are not always trained enough to spot these disorders in patients they see, nor is the population always educated enough to seek treatment themselves. Not only that, there is an extreme shortage of skilled mental health professionals even in relatively wealthy developing nations.

As a study published by The Lancet today shows, in these situations, lay health counsellors could provide vital support for mental health programmes in poor countries.

The use of lay health workers is highly controversial, and there are ferocious debates over how much responsibility they should be given, and what tasks can be delegated to them. These arguments are entirely valid - doctors are trained not just in medical knowledge but also in ethics. How much can a training course, however rigorous, compensate for years of experience? Still, while countries are trying hard to recruit health professionals, and trying even harder to stop them flying off to more prosperous countries, the shortage of staff is impossible to ignore.

Vikram Patel, a mental health expert at the London School of Hygiene and Tropical Medicine, UK, also runs a clinic in Goa, India. Patel has for some years argued that for countries like India, people with mental illness will continue to be neglected unless less formally trained healthcare workers are incorporated into the health system.

Now, Patel and his colleagues have found that adding a lay health counsellor to a team of a primary care physician and visiting psychiatrist meant that after 6 months, patients were much more likely to recover from mental illnesses such as depression.

The lay health workers effectively oversaw the patients' care from educating them about mental health issues, and advising them on ways to communicate their illness to family members, to coordinating non-drug treatments with the physician or psychiatrist.

Essentially, these health workers are the driving force behind ensuring that patients turn up to appointments, and that their care is well-coordinated - which can be difficult in remote areas. In patients treated privately, lay workers made no difference, which is perhaps understandable since private care is likely to be more personalised and have a better ratio of doctors to patients.

If properly trained and supervised, there doesn't seem to be any reason why health workers shouldn't have some role in delivering healthcare. After all, without them, some patients have no healthcare at all.

Should India refuse foreign aid?

With an economy that is continuing to gallop ahead, should India still receive overseas aid from countries like the UK? That's what Andrew Mitchell, the UK’s secretary of state for International Development, and Pranab Mukherjee, India's finance minister, met to discuss last week.

India has for some time struggled with an identity crisis. It is battling to reconcile its image of emerging superpower, that has itself given millions in aid to countries like Sri Lanka and Pakistan in times of crisis, with the reality of being a nation that is still home to a large proportion of the world's poor.

India's rich are getting even richer, and this wealth is starting to manifest in startlingly crass extravagances. Witness, for instance, the billion-dollar, 27-floor monstrosity of a house recently built by the Ambanis, one of the wealthy Indian business dynasties.

Yet India is still ranked 119th among 169 countries in the latest edition of the Human Development Index (HDI) published last month. This means India is well below similar emerging economies such as China (ranked 89) and even behind poorer neighbours such as Sri Lanka (ranked 91).

The HDI ranks countries on measures of well-being such as life expectancy, education, and standards of living. Under the shiny visage of India's economy, indicators such as the HDI are particularly telling, revealing the extent to which the government still neglects much of its population. India's social development lags so far behind its economic development that it is a scandalous betrayal of its poor.

December 1 was World AIDS day, and India has a staggering 2.5 million people with HIV. Understandably, many Indians feel frustrated that their country's image in the West is too often one of dirt and disease.

There's much more to India than that, it's true. But though India might want to feel that it has moved beyond the dependency of foreign aid - and countries like the UK might wonder why they are still giving millions to a country that is rich enough to have a competitive space programme - until the government honours its duty to all of its citizens, not just the wealthy and privileged, it is too early for aid donors to give up their commitments.