By Michelle DuMond and Cliff Sung——

Thailand is one of the most beautiful and prosperous economic centers in Southeast Asia. Unfortunately, it has become a hub for seekers of sexual services. The warm climate and bustling tourism industry provide a naturally hospitable environment for the sale of sex to international tourists and local clients. As a result, the country has become a magnet for traffickers of vulnerable women and children for the purpose of sexual exploitation. The problem in Thailand has become notorious throughout the world, yet the problem persists.

While the Thai government diplomatically remains in denial of its licentious vacationland reputation, officials are undoubtedly aware of the profits generated by the sex bars, strip clubs, and abundant streetwalkers. Interestingly, the Tourism Authority of Thailand (TAT) was established during the Vietnam War, which is credited for the explosion of commercial sex work throughout Southeast Asia. Some critics have even gone so far as to argue that the entire ministry of tourism began as a glorified cover for the government to continue the massive profits from sex tourism that began during the war. Though the official Tourism Authority does not directly advertise sexual opportunities available for tourists, it does so second-handedly. By advertising the hotels, bars, and nightlife, the TAT inadvertently advertises the sex market because in reality, the two are almost always intertwined on the streets.

Although the Thai government has made efforts to combat trafficking, there are still undeniable policy failures that have allowed the sex trafficking trade to thrive and continue. In 2011 the Thai government was placed in Tier 2 for the second consecutive year in the US Department of State’s Trafficking in Person Report (TIP Report) for failing to comply with minimum standards related to the elimination of trafficking. Law enforcement efforts in 2010 yielded a dismal 18 convictions in trafficking-related cases. In the past few years there have been fewer than 100 prosecutions each year for trafficking offenses, despite the obvious prevalence of the trade throughout the country. In addition, the number of sex-trafficking victims receiving protection from the Thai government declined in the TIP report, from 309 in 2009 to 88 in 2010. This decline was certainly not due to an overall decline in trafficking. 

Ostensibly, the Thai government encourages legal prosecution of traffickers by victims. In practice however, legal costs, corruption, slow legal processes, and fear of retaliation prevent victims from going forth with any litigation. In 2010, there was not a single case reported for which the Thai government provided financial or legal aid for sex trafficking victims to prosecute. In addition, while the government provides for residency status to be granted to stateless foreign victims, not a single case of residency has been granted to date.

The exploitation of trafficked victims for the sale of sexual services is an abomination of human rights and is a recurrent source of new incidences of sexually transmitted infections, including syphilis, HIV, gonorrhea, and hepatitis B. As increased information sharing through the internet and international news coverage has raised awareness about this issue, the international community is increasingly pushing for change. 

In fact, several institutions have already begun this process. ECPAT (End Child Prostitution and Trafficking) and ESCAP (Economic and Social Commission for Asia and the Pacific) are two examples of government and industry cooperative organizations uniting to fight the injustices of trafficking and sexual exploitation. These organizations are providing ways for hotels to advertise themselves as “trafficking-free establishments,” modeling after the “green” tag targeting eco-responsible tourists. These organizations also provide ways for the entertainment industry to directly decrease the sexual exploitation of children. They offer scholarships to train underprivileged and vulnerable children with transferable skills in the industry such as housekeeping, cooking, waitressing, and concierge services. Successful graduates are then offered positions for full time work with the hope of providing them with a legitimate way of life and keeping them away from traffickers. While many of these programs are still in the pilot stage, the “exploitation-free” reputation for hotels and tourist companies could become the next big tourist phenomenon, and it is a great way for the international community to help Thailand limit the profitability of the sex trade while not undermining tourism profits.

In addition to programs by outsiders, the Thai government has made some recent efforts towards responsible approaches to tourism promotion that should be commended. The TAT itself is partnering with UNESCO and other human rights organizations to work towards more responsible approaches to its promotion and financial gain from tourism. The country has also recently launched its second six-year National Policy Strategy on human trafficking to span from 2011-2016. Partnerships have been established with both NGO’s and local nation governments to increase awareness and provide protection for victims. Anti-trafficking memoranda of understandings (MOUs) have been drafted with Cambodia, Laos, and Vietnam, and provisions are underway to allow for better protection of victims, rather than returning them to their home countries and leaving them vulnerable for re-exploitation.

There is still an incredible amount of work to be done to clean up Thailand’s complicated relationship with the sex trade and trafficking revenues. Despite some recent progress, overall the Thai governments’ efforts to stave off the sex trafficking trade have been woefully inadequate. Policy changes that have been made are often ineffective in practice and may be viewed by some as a form of permissiveness through passivity. However, there is promise in developing partnerships with NGOs, neighboring countries’ governments, and industry. With added focus, political resolve, and more dedicated multi-national efforts, especially in the execution of national strategies, sex trafficking in Thailand may eventually turn the corner. 

Cliff and Michelle are fourth year medical students at the Stony Brook University School of Medicine. Both are pursuing medical careers in international health and have been frequent contributors at their school, as well as nationally.  Michelle is especially focused on sex trafficking issues in Southeast Asia and Cliff holds broad interests in tropical medicine. 

Last month, four AIDS advocacy programs and one former prison inmate took the unconventional, and rather inspired, step of suing the Canadian federal government for not providing a clean needle exchange program to the country’s prison inmates.  Their argument, based on the premise that the government must provide prisoners access to the same healthcare services as would be available to them in the community, is unlikely to succeed in Canada’s courts. It does, however, bring to the forefront important public health issue.  

Harm reduction has been shown time and time again to be an effective public health measure to curb the prevalence of communicable diseases such as HIV/AIDS and hepatitis C that can be spread via shared needles. The need is there. Prevalence of HIV/AIDS in prisons vary from country to country; however, globally infection rates are consistently higher in prison populations than in the general community. In Canada, estimates of HIV/AIDS prevalence in incarcerated populations are as much as ten times higher compared to the rest of the country.  And, remarkably, Hepatitis C infection rates in prison are even worse. Peer-reviewed studies consistently demonstrate that hepatitis C infection rates in prisons ranges from 20 to 40 percent. While these numbers are astounding, they are perhaps not unexpected. According to the Correctional Service of Canada (CSC), approximately 80 percent of people incarcerated have a serious substance abuse problem. So, is it really any surprise that a large percentage of inmates find ways to continuing using injection drugs once they are in prison? 

North America has always been squeamish about harm reduction. It is unclear where this attitude originates; both Canada and the United States strive to be progressive world leaders in a plethora of other sectors regardless of “conventional” wisdom. Yet for some reason, these nations have failed to take a leadership stance when it comes to public health. In Canada, there has been a long and disturbing history of the government acting contrary to compelling evidence supporting harm reduction measures. Some of the more notable failures include in 2006, when then federal public safety minister Stockwell Day cancelled an initiative to provide safe tattoos in prisons. This is despite a CSC report stating that the program was found to reduce the health risks of the inmates, prison staff members and the community at large. More recently in early 2012, a study done by the University of Toronto at the city’s request urged that both Toronto and Ottawa implement safe-injection sites in the community, following the example set by their Canadian colleagues in Vancouver. Despite these unambiguous recommendations, the province’s Minister of Health was quick to state that no further action would be taken on the issue.

Not only have governments ignored arguments put forth by public health or social justice advocates, they have also failed to heed the advice of economists. One study estimates that in the United States, a clean needle exchange program would cost approximately 34,278 USD per HIV infection averted, significantly lower than the cost of providing treatment to an HIV/AIDS positive person throughout their lifetime. Though the number of studies done on needle exchange programs in prisons specifically is limited, researchers have shown that clean needle exchange programs in the general community are cost-effective. One Australian study concluded that community needle exchange programs were not only effective, but that they would yield a ten-fold return on their initial investment.

Part of the reason for this seemingly mystifying failure to act is rooted in the common perception that harm reduction measures will encourage drug use. Policymakers also fear that needles given to inmates might be used as weapons, compromising the safety of the prison staff as well as the other inmates. While these are both understandable lines of reasoning, they have both been shown to be unfounded concerns. In programs that have been implemented in several countries, the levels of drug use within the prisons remain consistent at worse, and have even been shown to improve. Moreover, there have been no reports of the needles being used to intentionally to incite violence.¹

Another common justification against harm reduction measures insists that the government should not take such a “soft” stance on drug users. This attitude equates government action to that of an overly lenient parent failing to discipline an unruly child. Yet the difference in the situation at hand is obvious: by failing to provide a clean needle exchange, the government is actively promoting conditions that put an addict at risk of increased health problems. In no world is drug addiction an easy battle to overcome; only by lowering risk for HIV/AIDS or hepatitis C can addicts increase their chances of breaking of the cycle of drug use and recidivism. 

That fact of the matter is that North America is falling behind. To date, there are 60 countries worldwide that have taken strides to implement safe-needle exchange programs in their country’s prisons, including, of all places, Iran. Even in Iran, where freedom of speech is disallowed and where the government does not believe in the Holocaust, policymakers no longer ignore the towering mountain of evidence that supports this pubic health intervention. If they can do it, so can we. The need is there and the evidence is there; all we require now is the will.

Vicki Lee is currently completing an internship at an NGO called HealthBridge, working to encourage the healthy development of cities in low- and middle-income countries. She is also in her second and final year of a Masters in Public Health degree from the University of Waterloo, which she hopes to put to use in a career in global health.

¹Dolan, K., et al. (2002) Prison-based syringe exchange programme: a review of international research and development. Addiction, 98: 153 – 158

The degree to which skin pathologies plague individuals in the developing world is often overlooked and underestimated.  In fact, dermatological needs in less-developed countries account for an exceptionally high degree of disease burden.  In areas such as western Ethiopia for example, studies have identified up to 67% of all patients with skin problems, with numbers as high as 80% in schoolchildren.  Similar prevalence is seen in other discrete areas of the world such as Nepal or Brazil (62.4% and 87% respectively, all patients).  Yet, as is true of most medical subspecialties, there is an unfortunate dearth of dermatologists in the areas where they are needed most.

In contrast to the developed world, major dermatologic culprits are often infectious in nature, with bacterial, fungal, and parasitic agents all prominent.Pyoderma, tinea, and scabies are all among the most common skin infections seen in tropical areas especially.  Many infections are transmissible, and living conditions where high humidity and cramped housing predominate translate to excessively high rates of pathogen spread. 

Fortunately, many of these most common pathologies are easily treatable. The majority of bacterial and other infectious agents can be appropriately managed pharmacologically, and thus represent an important avenue by which disease burden can quickly be reduced. However, treatment failure rates are often as high as 80%, due to lack of specialists and inappropriate management.

Treatment of other dermatologic pathologies presents a greater challenge.  Certain diseases, including leprosy, cutaneous leishmaniasis, podoconiosis, and human t-cell lymphotropic virus (HTLV), can be permanently debilitating.  Many of these diseases require months of treatment, and can nevertheless recur years later.  These more complex dermatologic conditions have long since left the public eye in the developed world (if ever present), but still persist particularly in tropical areas. They represent perhaps the most devastating and disabling skin manifestations in the developing world. 

Skin manifestations in the developing world also frequently arise from interactions with other medical conditions.  Most notably, during the past few decades, HIV has created an entirely new subset of dermatologic manifestations.  In countries such as Botswana, where the HIV prevalence rate has exceeded 25% in recent years, immunocompromisation creates a gateway for opportunistic infections, some treatable, some much more fatal.  Importantly, skin manifestations may be one of the first signals of HIV infection, creating a potential screening modality for early disease detection.  Kaposi’s sarcoma is an especially important manifestation of HIV, as it is a potentially fatal malignancy that can develop prior to immunocompromisation.  Other manifestations of infection include varicella, oral hairy leukoplakia, and a massive spectrum of other bacterial and fungal infections.

Finally, a condition commonly seen as a first world pathology – skin cancer – has become a rapidly increasing problem in developing nations as well. More than 5 million newly diagnosed skin cancers occur in the developing world each year. However, appropriate radiotherapy facilities are almost always severely lacking.  Fifteen African countries and several additional countries throughout Asia completely lack even a single radiotherapy site. In countries where therapy is available, the average radiation therapy machine to person ratio is several million to one.  Even more damaging than the lack of facilities is the absence of skilled surgeons needed for appropriate management of skin cancers.  Unmet demand for surgeons is an overarching and intractable problem that goes beyond the scope of dermatology alone. Yet melanoma, as the single fastest growing cancer in the world, will increasingly contribute to widening the gap of unmet need in coming years.  

The need for effective and appropriate training for dermatologists in underserved areas is thus imperative, to address both commonplace and more complex conditions. Encouragingly, the impact of effective training has been well demonstrated.  In primary health care centers in Bamako, Mali, for example, a single day of training on the management of skin diseases was effective in producing a roughly 40% improvement in diagnosis of disease (from 42% up to 81%), a 25% reduction in prescription costs, and a lasting knowledge base (measured up to 18 months post training) for appropriate disease management skills¹⁰. 

For medical specialists based in first world countries, new opportunities to be involved in global dermatology have also begun to develop.  For example, the African Teledermatology Project (http://africa.telederm.org/) was created to provide local physicians and health care workers in hospitals and clinics throughout Africa with support from physicians around the world. The premise and structure are simple. A local physician encounters a pathology whose diagnosis is uncertain or unfamiliar to them.  A picture and description is sent electronically to a trained dermatologist with knowledge of indigenous pathologies.  Diagnosis and management information is returned electronically and the problem is then managed locally.   The program, run by Dr. Carrie Kovarik at UPenn, currently reaches over 15 countries throughout the world including Botswana, Tanzania, and Kenya.   

Though clearly pressing, the need for trained dermatologists (or other appropriately trained health professionals) in the developing world has not received sufficient attention. As young professionals involved in global health, it is imperative that we do not ignore this need when considering our educational and professional pursuits. Opportunities exist for involvement in all academic disciplines.  Even students who don’t pursue dermatology as a career can participate in educational campaigns for earlier skin care detection, or encourage dermatologists at their respective universities to participate in projects like African Teledermatology. Regardless of the avenue of entry, work in global dermatology has the potential to significantly and expeditiously reduce disease burden. This dual need and opportunity should not continue to go overlooked.

Cliff is a third year medical student at Stony Brook University with interests in tropical medicine.  He has done work in the past in Southern Africa, Southeast Asia, and South America, as well as with GHEC, and is a new Akili Fellow this year.

By Nico Barawid——

Talk of sustainable development reached a fever pitch earlier this summer with the convergence of multiple issues, stakeholders, and representatives at the Rio+20 conference in Brazil.  The historic summit, formally called the United Nations Convention on Sustainable Development, galvanized the international community towards setting concrete goals for sustainable development. Much in the same way that institutions, governments, and private organizations had rallied around the Millennium Development Goals in 2000 as a way to improve the welfare of the world’s poorest, Rio+20 intended to initiate similar processes. In fact, Rio+20′s final outcome document, The Future We Want, set a target of 2015 by which a new set of Sustainable Development Goals should be concretized.

For all the exciting (and, arguably, much deserved) talk of environmental protection and climate change, it is imperative that those issues not be the sole focus of sustainable development.  Implicit in the definition of sustainable development is, as the name suggests, continued work on economic development more broadly. The idea is that considerations of long term viability, environmental and otherwise, be deeply embedded in the fabric of the work on development. For this reason, practitioners and students of global health should not only be interested in, but also actively engage with, the multilateral efforts to wed sustainability and development. 

After all, the key policy question in sustainable development is how best to improve human welfare in a resource-constrained environment. And what more direct measure of human welfare is there than health? The linkages between environmental sustainability and human health are both direct and hugely important for policy. Improvements in global health can be causes in addition to effects of successful sustainability policy.

The effects of a dirty environment on health are obvious.  One of the most egregious examples is the case of acute respiratory infections, which tend to be exacerbated by pollution.  According to the WHO, these diseases are the number one cause of death of children under five, a tragedy no doubt worsened by poor environmental conditions. Additionally, rising global temperatures will negatively impact the quality, quantity, and accessibility of water; a focus on sustainability therefore helps to ensure access to sanitary and affordable water.

The links of health to the causes of environmental change are a little more subtle yet crucial for understanding the scope of health in sustainable development. Recently researchers in development and climate change policy have linked adaptive capacity – that is, the ability of a community to adapt to the effects of climate change – to levels of education and health.  In other words, people are more likely to be in tune with their environment and therefore know how to adapt in the face of environment change only if they have sufficiently high levels of education. Thus, efforts to keep students in school like improving their health should help them understand the impacts of their individual actions on the environment.

The list of interconnections between health and the environment could go on and on. While there certainly is inherent benefit in having a clean environment for its own sake, why invest so much political capital for such an environment if there are no healthy humans to enjoy it? The very first principle of the Rio Declaration on Environment and Development from twenty years ago stated in unambiguous terms why we should care about sustainable development: “Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature.”

So, given the importance of health for sustainable development, what concrete role can global health advocates play in these discussions? First, they can help to ensure that health remains a central focus on the sustainable development policy agenda. There has been fear among some in the health community that the era of global health may have reached its peak.  Thankfully, with the lobbying efforts of the WHO, Rio+20 has now inserted numerous references to health. This sort of persistent effort needs to be continued. And secondly, researchers can continue to explore the interdisciplinary connections between health and sustainability.  Such a synergistic approach, especially in university education, can shed new light on comprehensive policies to tackle both problems.

The most common definition given of sustainable development is policy that aims to “meet the needs of the present without compromising the ability of future generations to meet their own needs.” And there is surely no more immediate “need” than human health.

Nico graduated from Yale University in May of 2012 with a degree in Economics. He will begin his studies at Oxford University in the fall towards a Masters in Public Policy. 

By Sonia Taneja——

What would the great city of New York be without the taxicab? We can say with a degree of certainty that it would be slower, hindering busy New Yorkers from swiftly negotiating their various and numerous journeys with a simple hand-wave. Perhaps it would be more fragmented, limiting the web of movement among and within the five boroughs. In carrying a city’s inhabitants, taxicabs carry the economy of an expanding metropolis.  They carry the city, itself. 

But what about the faces behind the wheels? The first thing I do when I get into a cab is name my destination and worry about how much money I will have to dish out for the ride. I certainly do not think about how long my cabbie has driven since his last full night of sleep or what he has eaten that day. Contact with one’s taxi driver is typically cursory and impersonal. The wellbeing of taxi drivers is naturally never considered by the average passenger, even when it could affect their own safety. The drivers are themselves embedded within a busy lifestyle and they normally do not recognize that they face serious health issues that they can treat or even prevent, especially since these problems are generally due to occupational requirements.

Taxi drivers often remain sedentary within their vehicles for the entirety of their shifts, which can last all day. Taxi drivers have been documented to work 60-70 hours per week and sleep for less than an hour between consecutive shifts. During their shifts, they are not able to take bathroom breaks due to lack of appropriate parking spaces for taxis in cities. The results? Physical and mental stress from a lack of sleep as well as an increased risk of falling asleep at the wheel. Back pain and a higher risk of deep vein thrombosis from sitting in one position for hours on end. A significantly higher risk of diabetes, obesity, cardiac disease, hypertension, and stroke. Kidney and urinary tract problems. These risks are exacerbated by their eating habits. While most New Yorkers can complain about their busy “on-the-go” lifestyles, this is ubiquitous the case for most New York City taxi drivers – not just for the average nine-to-five work day, but for up to twenty-four hours. This lifestyle along with a lack of proper parking spots, time, and money makes fast food the easiest, most affordable option.

Along with their health, taxi drivers may be the victims of crime or violence. Because they are known to be as ‘easy targets,’ sitting alone in their vehicles late at night and always carrying cash, cabbies have been mugged, injured, and even killed during their pick-ups. In 2010, the profession was named one of the most dangerous by CNN Money and Business Insider, the latter of which identified assaults and violent acts as the most common cause of death for cab and limousine drivers. Furthermore, drivers are also often misconstrued and treated as the perpetrators during the police investigations related to their own assaults, possibly because of the discrimination they face as a result of their professions or racial backgrounds.

Eighty-four percent of taxi and livery drivers in New York City are immigrants, about half of whom are from the West Indies or South Asia. Limitations commonly dealt with by immigrants and refugees are thus significant in the taxi driver population as well. In 2009, Councilman Eric Gioia and Bhairavi Desai, Executive Director of the Taxi Workers Alliance, conducted a survey in which they determined that taxi drivers in New York have an uninsurance rate of 52%, over twice the rate of the average New Yorker. A lack of health insurance is a common problem for America’s immigrants– typically, this is due to unfamiliarity with the United States healthcare system, the language barrier preventing them from a smooth insurance process, or even discriminatory treatment they experience that discourages them from working within the health system. Though speaking a patient’s native language and equal treatment are elements of culturally sensitive medicine that are a significant component of global health work, these same elements are usually not considered when working with local immigrant populations.

I began to appreciate the problems faced by taxi drivers during an internship at the Center for Immigrant Health and Cancer Disparities, an organization associated with Memorial Sloan-Kettering Cancer Center that has been a part of the budding solution for taxi driver health and human rights struggles in New York City. Its initiative to improve the quality of life for taxi drivers began with the STEP (Supporting Taxi Drivers to Exercise through Pedometers) program to encourage exercise within the professional community by distributing pedometers, allowing drivers to compare the average number of steps they take per day with what is prescribed for good health. From STEP sprang “Step On It! NYC Taxi Drivers Health Fair” a five-day event in September 2011 at the holding lot of the John F. Kennedy Airport, a frequent break location for New York City’s cab drivers. This event included free workshops, take-home resources in various languages, and screenings for cab drivers focused on improving their access to healthcare and insurance, increasing their physical activity, choosing healthier food options, reducing stress, and quitting tobacco use.

It’s time we start to care about the thousands of people behind the wheel and encourage efforts like those of the Center for Immigrant Health. Although global health professionals are making enormous progress for those living in the most underdeveloped nations, it is vital that we also address health disparities among the underserved in the developed world as well.

Sonia Taneja is a rising senior at Yale University majoring in Psychology who is primarily interested in issues surrounding cultural sensitivity required in healthcare delivery and global development. She will be writing about and pursuing these interests this summer by completing coursework at the National University of Singapore in development and heritage conservation and studying mental health in gynecological cancer patients in New Delhi, India. 

By Katherine Warren——

Every week, there is a new headline about the demise of Indian Country. Last month, the focus was the abuse of American Indian and Alaska Native women. In February, it was violent crime on South Dakota reservations. In early May, Nicholas Kristof highlighted pervasive alcoholism and the fight against beer companies.

As a researcher of violence against women, mental health, and suicide, I know all too personally what painful and persistent problems these issues pose. Alerting the rest of the country to the inequalities of reservation life is necessary and, in many cases, sorely lacking, particularly here in the Seattle area. But what consequences does such overwhelmingly negative media coverage have for American Indian and Alaska Native (AIAN) communities on the ground? If there is an epidemic of ‘hopelessness,’ as is often described, the calamitous tone of the media can only serve to heighten this depression.

The endemic disparities between Native Americans and their fellow U.S. citizens are undoubtedly appalling, but solutions to them will require more than incendiary news coverage. As Willow Pingree, a 19-year-old Wind River Reservation resident wrote, “Not EVERYTHING about this reservation is bad. Sure there is a huge problem with domestic violence and alcoholism, but we try to work together as a community to fight it…It is a sad thing that people are quick to judge a place where they have not lived.”

For young people like Pingree, the constant reaffirmation of reservation violence and addiction serves to further erode the community’s belief in their own agency. When I read the mainstream news coverage of the northern Plains tribes, I understand why people here on the Fort Peck reservation speak of widespread adolescent despair. 

What really makes these stories news? Many individuals and communities are certainly struggling in Indian Country after centuries of disenfranchisement and marginalization. Here in Montana, my neighbor was recently hospitalized for cirrhosis after years of alcoholism. A tribal leader has been indicted for driving under the influence and subsequently assaulting a police officer. But addiction, poverty, and crime among a single racial/ethnic group in a geographic region is not a phenomenon limited to Native American tribes. There are communities from Seattle to San Antonio that demonstrate similar issues of violence and non-communicable disease.

The outbreak of apocalyptic news coverage of AIANs is thus not solely a factor of circumstance. The myopic media fascination with Indian Country’s woes provides a classic example of the politics of representation. The relentless focus on the problems as opposed to solutions only justifies the need for lesser tribal sovereignty and increased federal regulation.

In many ways, this is what Arthur and Joan Kleinman call the commodification of suffering. The dismal portraits of basketball teams decimated by murder or families torn apart by sexual assault sell papers. Small-scale tribal economic development projects, some that work and some that do not, provide a less gripping headline. 

If we as a country want to see real change on reservations, we have to demand the coverage of hope and solutions alongside the painful exposés. The onus of responsibility is on all of us as media consumers. So the next time you read about reservation methamphetamine use or tribal obesity epidemics, find one alternative media source on the many AIAN communities effectively working for social change.

Look up the work of the Tohono O’odham Nation Police in addressing drug smuggling across the Mexican border. Find out more about the White Earth Suicide Intervention Team’s success in confronting a suicide rate that was 8.5 times greater than the American Indian average in 1990. Read the Navajo Times. Follow the entertaining and passionate Twitter feed of well-known Spokane writer Sherman Alexie, which demonstrates relevant social problems in the rest of the world at large. Sure, the same stories of violence and crime arise, but there are also stories of honor roll kids, watershed restoration projects, and domestic violence rehabilitation programs. Let’s make these projects news too.

Katherine Warren is Co-Director of the Akili Initiative and a senior anthropology major at Harvard University. She is currently working on the Fort Peck Tribes Indian Reservation in northeastern Montana.

By Benjamin Campbell——

Most people think cancer is a disease of the elderly or middle aged.  But as the world follows Suleika Jaouad, a 24 year old woman documenting her struggle with leukemia, it is clear that cancer can just as tragically affect young people. 

“In the year since my diagnosis with leukemia, I’ve struggled to hold on to a sense of who I am,” said Suleika, as she started to experience hair loss.  Her series, ‘Life, Interrupted’, brings us into a world of challenges and choices, from chemotherapy and the threat of future infertility, to feelings of helplessness from family and friends, to the uncertainty of a high-risk bone marrow transplant. 

But she’s not facing this challenge alone.  Suleika beams as she thanks countless supporters who have contacted her from around the world.  It’s not surprising that many people are getting behind Suleika in her fight, but what is interesting is that these supporters are mostly young women also battling cancer. It is a stark reminder that globally, death and disability due to cancer is a growing problem, especially for young women.

In a major report published last year, called “The Challenge Ahead: Progress and Setbacks in Breast and Cervical Cancer,” the Institute for Health Metrics and Evaluation (IHME) in Seattle wrote that “the most troubling trend” over the last 30 years is the number of deaths in women of reproductive age (15-49 years of age) due to these cancers.  The authors report that breast cancer deaths increased 1.5% per year and cervical cancer deaths increased 0.5% per year between 1980 and 2010.

And in certain regions, like East Africa, rates of death for young women are exceptionally high.  For example, in Uganda, 40.9% of women dying due to breast cancer are under age 50, while globally the percentage is 22.1%. 

One major reason for this disparity is that many young women in East Africa get diagnosed too late, usually when the cancer is already at an advanced stage.  According to Dr. Lehman, a radiologist at Fred Hutchinson Cancer Research Center who works in Uganda, “By the time these women arrive at the Uganda Cancer Institute, in most cases their breast cancers are advanced, and treatment options are limited. At this time, most women diagnosed with breast cancer in Uganda do not survive.”  To improve early detection and survival for these women, Lehman and colleagues are enhancing early detection of breast cancer through innovative ultrasound screening techniques. 

But this is just the beginning of a global effort to stem cancer deaths, especially in young women.  Only recently—at the UN Summit on Non-Communicable Diseases (NCDs)—has cancer prevention and treatment shifted from being a problem of the developed world to being a truly global issue, one affecting rich and poor alike.  And as a global community, we need to continue to back the movement. 

As we push this effort forward, let us not forget the daily struggles of Suleika and other young women around the globe.  Because as their lives get interrupted, so do their families, their communities, their world.  Our families, our communities, our world.

Ben Campbell is a post-bachelor fellow at the Institute for Health Metrics and Evaluation and he conducts research on the burden of cancer for the 2010 Global Burden of Disease (GBD) study.

By Vicki Lee——

On Monday April 16, 2012, the World Bank Group announced US nominee Jim Yong Kim as its next President, succeeding Robert Zoellick to become the twelfth leader of the world’s premier development organization. Despite his undeniably impressive accomplishments, the choice of Kim by the World Bank has been the brunt of much criticism, from the worlds of finance and international development alike.

An unconventional choice…

At first glance, Kim is an unconventional choice for the Bank. Unlike his predecessors, Kim has relatively little experience in finance or economics. Rather than having held high-ranking government posts, such as Zoellick or Paul Wolfowitz (the tenth President of the World Bank), or founding their own investment firm, such as James Wolfensohn (the ninth President of the World Bank), most of Kim’s experience lies instead in global health.

Early in his career as an M.D., Kim co-founded Partners in Health (PIH) in 1987, along with his colleagues Paul Farmer, Todd McCormack, Thomas White and Ophelia Dahl. Upon it inception, the organization focused on developing community-based initiatives to address the plethora of health problems plaguing Haiti. Later on, PIH tackled multi-drug resistant tuberculosis (MDR-TB) in Peru with resounding success.  In 1997, the WHO released the first edition of their Treatment of Tuberculosis: Guidelines for National Programs, which essentially stated that due to the expense of secondary line treatments, MDR-TB patients were not worth treating.  PIH, led by Kim and his colleagues, disagreed. Using their community-based model in the shantytowns of Peru, PIH achieved higher cure rates of MDR-TB than seen in the US at the time. Guided by their principle value of helping those in need regardless of the cost, PIH inspired change in the treatment of MDR-TB against all odds.

Kim also made dramatic strides in the treatment of HIV/AIDS, as the director of the HIV/AIDS program at the WHO. In his time with the organization, Kim spearheaded the 3×5 campaign, which aimed to provide AIDS treatment to three million people in developing countries by 2005. This was perhaps an overambitious goal, as 2005 came and went with approximately only one million people affected by the campaign, but it nonetheless reflected Kim’s need to take on the problems of the world’s most vulnerable. The goal of three million was eventually reached in 2007, and according to The Lancet, the initiative was deemed to have “changed forever the way we think about AIDS.”[1]

As Kim went on to hold several distinguished positions at Harvard and then serve as the President of Dartmouth College, he has continued to push the global health agenda forward through galvanizing student efforts. At Dartmouth, where he began his tenure in 2009, Kim launched the National College Health Improvement Project, aimed to address health issues that affect students. Whether talking about a rural village in sub-Saharan Africa or a college community at Dartmouth, Kim continued to inspire his students to be great. His inaugural address to Dartmouth urged, “Your generation must dream, dream more ambitiously than any who have preceded you. But just to dream is not enough. You must deliver on the dream where previous generations have fallen short.”

All of this has amounted to an impressive resume of accomplishments. Certainly if Kim was named the head of any international health organization, there would be no protest. But a bank? There is an uneasiness among some that Kim does not understand the world of economics, and even worse, vilifies it. In an interview with the Financial Times, economics professor William Easterly called Kim “anti-growth” based on Dying for Growth, a book Kim co-authored. In it, Kim says things like, “The studies in this book present evidence that the quest for growth in GDP and corporate profits has in fact worsened the lives of millions of women and men.” So the question is, can a man who is primarily interested in health effectively run an economic institution?

…But not a surprising one

Yet despite Kim’s unconventional background, the World Bank’s choice is not a surprising one. Since its establishment, the WB has followed the same pattern of choosing the nominee put forth by the United States, just as the head of the International Monetary Fund (IMF) has always been chosen by Europe. It did not escape the attention of many that the US was quick to back Europe’s choice of Christine Lagarde for the head of the IMF earlier in 2011, while vice versa was true of the US’s nomination of Kim.

This does not sit well with many in the international development field, given that the World Bank’s primary agenda is to help developing nations, which includes neither the US or Western Europe. Dissenters are quick to label the entire process a political game, devoid of meritocracy. In fact, one of the Kim’s fellow nominees, Colombia’s former finance minister Jose Antonio Ocampo, withdrew from the race, calling it too political. The only other nominee for the job was Ngozi Okonjo-Iweala, current finance minister in Nigeria. Highly respected and touted by many, including The Economist, as the best candidate for the job, Okonjo-Iweala has made it her mission to fight the corruption that plagues Nigerian politics, and has experience in economics, government and development – a triad that is critical to the World Bank.  Yet, despite Okonjo-Iweala and Ocampo’s strong resumes, the announcement of Kim as the next president of the World Bank surprised few. As Professor Simon Evenett, a former World Bank official, told The Guardian, “There was never really a contest…the West won’t give up its hold over these institutions until they need something from the emerging markets.”

Looking forward

The fact that the nomination process is political and US-dominated cannot be ignored. Without a doubt, the process lacks transparency and neutrality. Yet the very existence of protest and competition against the US nominee this year marks progress towards a more meritocratic process. Moreover, a flawed process does not necessarily preclude the selection of exceptional candidates. No one doubts Kim’s sincerity to international development, and his wealth of experience surely means that he knows international cooperation will be vital for success. In a statement he released after being announced as the next President, Kim stated he had already spoken to Oncampo and Okonjo-Iweala, and was eager to draw upon their knowledge during his tenure.

Furthermore, while he does not have formal training in economics, Kim is not without experience. Let’s not forget that for the past three years as Dartmouth President he has been at the helm of a major institution, which includes its financial planning. Moreover, accusations that he is “anti-growth” seem to be exaggerated. His former partner Paul Farmer wrote an op-ed for the Washington Post, stating that Kim’s statements in Dying for Growth were taken out of context and that. If anything, Farmer wrote, their prose is pro-growth, seeking new ways to encourage inclusive development for countries in need while simultaneously “raising questions about particular policies and patterns of growth that exclude the great majority of people living in poverty.” All this actually fits in rather well with the World Bank’s mission to help reduce poverty, and to encourage development of the world’s poorest countries. What better person to help the world’s poorest develop, than someone who has worked intimately with them, and has already made it his mission to help them?

Vicki Lee is currently a scientific reviewer for clinical trial pharmaceuticals at Health Canada. She has a B.Sc. in chemistry and is currently completing a Masters in Public Health from the University of Waterloo, which she hopes to put to use in a career in global health.

Coverage of the National Collegiate Inventors and Innovators Alliance (NCIIA) Conference in San Francisco, CA by Benjamin Campbell

Is the iPhone an innovation?   You’re probably thinking, “of course.”

Ask the same question to folks in rural India, and you’ll hear a resounding, “Of course not.” iPhones are from a corporation. Innovations come from individuals.  This sentiment was voiced by many others in a recent Penn State study probing an important question:  How do people in resource-constrained environments think about innovation?

For this ethnographic study, researchers interviewed over 400 youths across rural and urban areas of Kenya, Tanzania, India, and Nicaragua with 120 interviews planned for September 2012 in resource-constrained areas in the US.  Although the study is still underway, preliminary findings, presented at the NCIIA conference this March, reveal some interesting themes. 

For one, men and women think very differently about innovation.  In Kenya, for example, men felt connected to the global community and as a result, understood innovation to be products and services available to most developed countries.  On the other hand, women tended to believe that innovation happened at the local or household level.  This could reflect several contextual realities, including gender norms as well as differences in access to education between men and women. 

Preliminary results also show interesting differences across countries.  Respondents in Kenya believed innovation was about making an income and developing a fruitful livelihood, whereas many folks in Tanzania believed that the purpose of innovation was to preserve cultural identity.  When prompted, Tanzanians frequently claimed that traditional medicines were an example of innovations and tools for cultural preservation.  When new traditional medicines are made, indigenous knowledge is not revealed widely, but passed along to other healers, preserving the culture. Importantly, many also mentioned that these new medicines saved them money because they no longer had to spend money to see a physician. 

These ideas can clash or merge with salient western notions of innovation and enterprise.  For example, patents are enshrined as a way for inventors to protect an innovative idea in the west.  Patents are constructed for individuals to preserve a specific idea.  In Tanzania, as this study suggests, innovative ideas are not to be owned by a single individual, but an entire community, bound by a cultural identity.  Patenting a new traditional medicine might very well be considered cultural theft to Tanzanians.  Also, western enterprise emphasizes bringing innovations to scale. In other words, it is assumed that a product designed in one location should, ideally, be produced at a large scale to reach a maximum number of consumers.  If new traditional medicines are only meant to be shared with members of a single community or culture, scaling these products to other areas does not seem logical.  In contrast to these differences, the Tanzanian respondents seem to consider cost in their valuation of which provider to see.  This is consistent with western business thinking.

These are interesting ethnographic findings, but so what?  What kind of implications are there?   For one, there is a growing demand for cross-cultural entrepreneurship experiences.  Another session at NCIIA, entitled “Collaborative Guatemalan Summer School” presented by Pete Schwartz and Jamie Cignetti of California Polytechnic State University, illustrated that there is a demand among students, both in developed and developing setting, to take a multidisciplinary course in Guatemala on entrepreneurship, sustainable energy solutions, and development.  As programs like this develop and expand to other schools, there needs to be a corresponding discussion about how host communities understand innovation and how this might merge or clash with salient western perceptions of innovation and entrepreneurship. 

Secondly, these kinds of findings could have implications for major corporations, which have shown an increased appreciation for “reverse innovation.”  Reverse innovation, also known as trickle-up innovation, is a term used to describe innovations created in the developing world that can be highly cost-effective in the developed world.  In an article in the Harvard Business Review, General Electric CEO Jeffrey Immelt and colleagues said that bringing innovations from the developing world to the developed world would both provide access to emerging markets and allow companies to pioneer new sources of profit in wealthy countries.   If this trend continues, it will be important for companies to keep in mind cross-cultural understandings of innovation so as to maintain healthy, respectful relations with the partner stakeholders.  Also, as major companies try to expand goods globally, it is critical to keep in mind local values, practices, and understandings of innovation. 

In the Penn State study, one other theme that emerged was the idea that cross-cultural communication and working with western companies in and of itself is an innovation.  It is a reminder that as our world becomes truly global, we must be very mindful and respectful of the partnerships we form in our effort to innovate for a healthier world. 

For more information on the conference, please see NCIIA’s website and partnering organization, the Consortium of Universities for Global Health.

Coverage of the National Collegiate Inventors and Innovators Alliance (NCIIA) Conference in San Francisco, CA by Benjamin Campbell

In 2007, the President of Gambia, Yahya Jammeh, claimed he could cure anyone of HIV/AIDS in three days.  What’s more, he said he could do it for free.  Despite international outcry, many Gambians joined Jammeh’s program, and some even claimed they had gained weight and were cured as a result. 

Now imagine you are part of an organization trying to provide services to people infected with HIV in Gambia.  You conduct a survey to learn about the demand for your services and find an uneasy result: no one is willing to pay for it. In other words, they see no value in the service.  But this shouldn’t come as a surprise. After all, why would the people pay when they can be cured of the disease in just three days, for free, by their president? 

Here, an aspect of an entrepreneurial venture – expectations of payment—can collide with efforts to engage a community about a seemingly needed service.  This tension is pronounced in the Gambia example, but it exists in many forms, according to a team of researchers at Penn State University in the Humanitarian Engineering and Social Entrepreneurship (HESE) Program.  In their paper and presentation at the NCIIA Conference, entitled “When Participatory Research and Business Strategy Collide,” the authors highlight some other key themes that entrepreneurs and researchers should consider in developing settings. 

For instance, entrepreneurs seeking entrance into certain communities or trying to gain access to target populations must be highly cognizant of power structures and cultural norms.  Trying to integrate a venture into a community can be collaborative and fruitful, but if attempts to negotiate resources lead to a power struggle among community leaders, the venture can break trust and cut access to participatory research opportunities. 

But why are research pursuits important in the first place?  Participatory research, according to the Penn State University researchers, is absolutely critical in identifying community problems, articulating the context and resources needed, and finding appropriate, effective and sustainable solutions (1).  The research itself can also build rapport between entrepreneurs and the community.  

However, there are also times when conducting participatory research can have negative ramifications for the entrepreneurial venture.  In their paper, the authors point to several key ways this can happen. 

First, in research, community members may share opinions about the business model for the venture and expect these views to be used.  If the business model does not ultimately incorporate these views, some community members may feel disrespected and decide not to use the product.  In order to avoid this situation, the authors suggest that researchers should be extremely clear and explicit to all stakeholders and community members about the purpose of the research.

A second way that research can collide with a business venture is that it can provide limited information in efforts to scale up.  If resources are limited for research, a venture may only invest in a study in one location.  However, because of significant cultural and socio-demographic variation across regions, the research findings may not be useful for other sites.  If the venture chooses to replicate their model in many locations based on research findings in one area, the venture may fail. 

Lastly, when researchers give products for free or other incentives to encourage participation, community members may expect it to be free in the future.  If the venture chooses to later charge for the product, people may not be willing to invest in it. 

The importance of quality research to business model development cannot be overstated.  However, as the Penn State researchers emphasized, there are certain circumstances where these efforts can collide.  With increasing levels of entrepreneurial ventures in developing settings, it is critical to be mindful of these potential collisions and to make sure limited resources are maximized.

Citations

(1)   A. Grzybowski, B. Mathias, K. Mehta, “When Participatory Research and Business Strategy Collide:  Lessons from Base-of-Pyramid Ventures.” Peer-Reviewed Paper for NCIIA Conference 2012.