(Formerly called IRIN) Journalism from the heart of crises

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  • Prostituted, beaten and held for ransom

    As warmer weather brings calmer seas, more and more migrants are setting off again from the Libyan coast in smugglers’ boats bound for Italy. Eight vessels containing 1,361 people were rescued from this stretch of the Mediterranean on Wednesday alone, while dozens more are missing feared dead after their boat sank. Since the beginning of the year, more than 16,000 migrants have used this route. For most though, the journey begins on the other side of the Sahara and involves not only a treacherous desert crossing but also running the gauntlet of Libya’s people-smuggling networks.

    The outskirts of Libya’s main southern town and Saharan smuggling hub look post-apocalyptic. Charred frames of burnt-out cars are lodged on top of smouldering rubbish heaped by the roadside, and tracks snake off through the dirty scrubland towards half-finished houses.

    This is where people smugglers, who cram up to 31 people at a time into Toyota pick-up trucks for the three-day journey from Niger through the Sahara Desert, drop their customers. 

    Some are met by friends, relatives or smugglers, while others walk towards the town. But, although initially thankful to have survived the harsh desert crossing, migrants told IRIN the arrival in Sabha heralded the worst part of their journey to the eastern Mediterranean.

    “When we arrived, we were immediately taken to a kind of prison, a house where there were about 200 other migrants,” said 19-year-old Bouba from Senegal. “They made us call our families back home and demanded that they sent 2,000 Libyan dinar ($1,458) for each person.”

    Jens, 24, from Guinea Bissau showed scars on his arms and back, which he said were from brutal beatings inflicted by his captors. “They beat me and kept saying: ‘What’s wrong with you? Why don’t your parents send the money? Don’t they love you?’ It was horrible, but my family has so little money that it took them two months to borrow enough to pay for my release.” 

    Both men now live in a rough shack on a rubbish dump in Sabha, with 24 others. They are all trying to find work to pay the 500 dinar ($365) it takes to reach the Libyan capital, Tripoli, closer to the sea and a boat to Europe.

    Tribal complications

    Passage through Libya has long been the main route from Africa to Europe. Today, the main path for sub-Saharan Africans to reach the Mediterranean coast is organised between several regional tribes and runs from the city of Agadez in central Niger to Sabha.

    The desert route is worked almost exclusively by the Tabu, a semi-nomadic Saharan tribe populating harsh and inhospitable terrain with few opportunities in Libya, Chad and Niger.

    With other powerful Arab tribes dominating the smuggling of goods, people smuggling is one of few lucrative job prospects. But after a series of fierce tribal conflicts in the town, much of Sabha is now off-limits to the Tabu.

    “Often the migrants have a contact number of someone in Sabha and I just drop them there, on the outskirts. If they don’t know anyone, I leave them with some Arab guy but that is not my business,” 29-year-old people smuggler Adem told IRIN. “My job is to get these people from Agadez to Sabha. That’s it. After that, I don’t care.”

    For their onward journey, migrants are forced to rely on members of several Arab tribes, some of whom work with middlemen. 

    Miserable way station

    “Sabha is just a terrible place,” said Nigerian electrician Sammy, 35, now working in Tripoli. “When I arrived there, the Nigerian middleman said I owed him money for the journey he helped organise. I had my passport taken and was imprisoned. They demanded $2,000 and I had to phone my mother and ask her to sell all my possessions, including the family’s generator. But that only made the equivalent of 300 dinar ($219).”

    He described how he was forced to work for eight months in Sabha to make enough money to pay the outstanding balance. “I worked like a slave in a house for African prostitutes, where I cleaned, cooked for the women and washed their clothes,” he said. “They were prisoners too, but captured migrant women are forced to be prostitutes in Sabha. Some of them were from Nigeria, like me. Imagine: I had to watch my sisters being used in this way. They were paid $10 to have sex with disgusting old men. It made me feel sick, but I could do nothing to help them.”

    A young Nigerian woman, Marie, 23, said she narrowly escaped this fate after the woman who arranged her journey to Libya, with the false promise of a retail job in Europe, turned on her in Sabha. “Her Libyan boyfriend came to meet us and they told me I had to pay 2,000 dinar ($1,458) if I wanted to continue my journey. When I said I couldn’t pay, he said: ‘you will use your body to get the money’. But I refused,” she said. 

    “They made me call my mum and put the phone on speaker and beat me so my mum could hear me screaming.” Her captors eventually accepted a smaller sum, which a distant relative brought, in person, from Tripoli.

    Sabha resident Ahmed showed IRIN the location of several huge warehouses where he claimed migrants, especially women, were kept. At night, he said, the warehouses became ‘dens of inequity,’ where alcohol and prostitutes were available, and music blasted out across the town. “One tribe runs that area and no one from any other tribe can enter,” Ahmed said. ”Even the army cannot go there.”

    Lawless and powerless

    Sabha is one of Libya’s most lawless towns, where deep-running tribal divisions mean large parts of the city are inaccessible to residents, depending on their tribal background. “Nobody controls Sabha and no one feels safe here,” said Ahmed. “The Third Force [a ‘peacekeeping’ force from Libya’s third city of Misrata] say they are in control, but they actually only control one neighbourhood.” 

    Frustrated security officials admit that undocumented migrants are the least of their problems. “The crime rate here is not 100 percent, it is 150 percent,” said a senior police officer in Sabha, who spoke to IRIN on condition of anonymity. 

    “Even to leave the house wearing a police or military uniform puts you in immediate danger,” he explained, adding that for the last two years he has slept in a different place every night, to avoid being killed. 

    Underfunded, ill-equipped and with staff too afraid to work, the local Department for Combatting Illegal Immigration has not functioned properly for several years. Sabha’s migrant detention centre, eight kilometres outside the town, stands empty, only reachable with a heavily-armed escort. 

    The police officer said controlling the people-smuggling operations in Sabha was impossible. “Even the migrants know we are powerless,” he said. “Before, when they saw us, they ran away. But now they just stand there and stare at us.”

    Migrant truck back to Niger.jpg

    Truck with chairs hanging off the back
    Tom Wescott/IRIN
    Migrants pile on a lorry already laden with goods in an effort to return to Niger on the cheap
    Inside southern Libya’s lawless people-smuggling hub
    Prostituted, beaten and held for ransom
  • Africa’s meningitis A vaccine: how partnership replaced ‘Big Pharma’



    Four years after it was first used in a mass vaccination campaign, the MenAfriVac vaccine has achieved an extraordinary outcome; cases of meningitis A have dropped to almost zero in the epidemic belt across Africa.

    But if it hadn’t been for an experimental partnership between the World Health Organization and the not-for-profit health organisation, PATH – working without the involvement of multinational pharmaceutical companies – the vaccine might never even have been developed.

    Outbreak season in the so-called meningitis belt across the Sahel starts annually in late December. Every 10 or 15 years, conditions come together to set off a major epidemic. In 1996-7, there were more than 250,000 reported cases; more than 25,000 people died, and many more were left with permanent disabilities.

    After that epidemic, African governments came together and demanded that something be done. More specifically they wanted an effective, affordable vaccine that could be rolled out across the region.

    The problem: there wasn’t one. The only vaccines available were tailored to the strains common in Europe and North America, not to Meningitis A, which caused the epidemics in West Africa. They were also far too expensive for a mass campaign in the region.

    As ever, the problem was money. Meningitis A affected poor people in the poorest regions of some of the poorest countries in the world.

    For global health specialists, this is a sadly familiar problem. Mogha Kamal-Yanni, senior health advisor at Oxfam, says the situation is typical. “Clearly the current model of research and development is not working,” she told IRIN. “It's a broken model, failing public health. It's not producing what we need, or else it's unaffordable.”

    The unwillingness of pharmaceutical companies to invest in a disease that affects the poor has been widely blamed for the lack of a vaccine against Ebola, which seriously hampered the response to the recent outbreak in West Africa.

    But this time, in response to the appeal from African governments, the WHO and PATH set up the Meningitis Vaccine Project with the objective of getting a vaccine approved and into production. With $70 million from the Bill and Melinda Gates Foundation to oil the wheels, they began by approaching the big pharmaceutical companies. “That was the accepted approach at that time,” says the project manager, Kathleen Tiffay. “And that was what people expected.”

    Negotiations, however, soon stalled. Two big companies were interested, but finally, after 18 months of negotiations, they said they couldn't bring the price down below $2 a dose; the project's target was 'under 50 cents'. Discussions with another company, which owned technology needed to produce the vaccine, also collapsed, again over pricing. “There was just too big a gap,” says Tiffay.

    That – she told IRIN – was the low point. “We had hoped we could have it set up and ready to go in a year or a year and half. Everything was taking much longer than our estimates.” Finally, those behind the Meningitis Vaccine Project decided to go ahead and do it themselves. “And to be realistic,” says Tiffay, “we weren't any slower than Big Pharma; in fact we were probably faster.”

    They describe what they did as setting up a kind of virtual pharmaceutical company. While the big established companies could have done everything in-house, they had to put together a series of partnerships – to supply the ingredients, license the technology, do the clinical trials and get all necessary approvals, and to manufacture the vaccine. Some partners, like the manufacturer, the Serum Institute of India Ltd (SIIL), were commercial companies. Others were public bodies. The US Food and Drug Administration licensed a conjugation method at negligible cost and supported transfer of the technology to the Indian company. Britain's National Institute for Biological Standards and Control worked on the licensing. The clinical trials were done with national partners at eight study sites across Africa and India.

    The whole essence of this approach is that there is no permanent organisation, but a coalition of public and private partnerships forged afresh for each project, and tailored to its specific needs.

    The final product, MenAfriVac, has proved effective, safe even for infants, thermostable without refrigeration, and is now being produced in India for just 40c a dose. Although, in the end, the big multinational drug companies weren't involved in producing the vaccine, they didn't try to stop it, and the big companies that make up part of the board of the Vaccine Alliance, GAVI, supported the use of GAVI funds to pay for the mass vaccination programme.

    Another similar and even more ambitious project is in the pipeline, again led by PATH and the WHO, using the same Indian manufacturer. The plan is to produce a vaccine that will protect against five different strains of meningitis – A, C, Y, W and X. This time the funder is the British international development agency, DFID. Its Research for Development arm has allocated more than 5.5 million US dollars to develop a vaccine against multiple strains of meningitis and take it as far as Phase I trials. Clinical trials will start in January.

    Marie-Pierre Preziosi of the WHO, one of the directors of the vaccine project told IRIN: “The initial phases were challenging because the landscape was complicated by there being a lot of existing patents. We needed to find unpatented technology for all the different strains.

    “But in the end, if the clinical trials are successful, the product will be very affordable and there will be a high demand from affected countries.”

    So is this the way forward?

    Not so fast, says Tiffay. “The whole way that vaccines and drugs are being currently produced is very dynamic. It's evolved a lot since we began the Meningitis Project and started transferring technology and working with developing countries. But the next time would be different, because the whole field has changed, and each disease and each vaccine is different.”

    Preziozi also says one size won't fit all. “In this case,” she says, “there was a clear call from WHO member states, and an identifiable solution existed, but no product was available. But if you want to go with different types of vaccine where the technology is not available, then you might need to go with a different approach.”

    So can you do without the big companies? “No, no, no. Always there will be a need for Big Pharma to be there,” she says. “Because research and development is very costly.”

    Oxfam's Kamal-Yanni agrees. She says multiple models are needed, and where there is substantial research and development work to be done, the big drug companies will be essential. “The key thing we need to do is to delink the cost of R&D from the cost of the resulting product. So then the issue becomes how to finance the R&D, and that could be by up-front grants, for instance, or by research prizes awarded for progress at each stage of development.”

    (Further reading on the Meningitis Vaccine Project)

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    A new approach to vaccine development
  • Why isn’t Guinea-Bissau prepared for Ebola?

    The government of Guinea-Bissau has known for months about the risk of Ebola entering the country, but it hasn't done enough to prepare. Now there is a cluster of cases just across the border. Residents say it will be good fortune rather than good planning if an outbreak is avoided.

    “I don’t know why we haven’t gotten Ebola yet,” said Edimar Nhaga, who lives in the capital, Bissau. “It certainly isn’t because of prevention measures taken by the government because they haven’t done enough to avoid the epidemic. I believe it’s been luck so far because, to be frank, we just don’t have the capacity for a proper response. No one should believe that our country could face a hypothetical Ebola outbreak.”

    As of mid-May, Guinea-Bissau had implemented just 59 percent of the minimum preparedness tasks, including having measures in place for proper epidemiological surveillance, public awareness campaigns, case management, contact tracing, and safe and dignified burials, according to the latest data from the World Health Organization (WHO).

    The country has not yet identified funding sources or developed a framework in case an Ebola outbreak should occur, WHO reports, and just 20 percent of minimum preparedness activities related to budgeting, including the creation of easily accessible contingency funds for immediate response to a potential case, have been completed.

    “Guinea-Bissau is definitely a matter of concern,” said Doctor Unni Krishnan who heads Plan International’s Disaster Preparedness and Response program. “If a case arrives, this could either go the way in which Ebola was contained in Nigeria because of quick action and good preparedness measures, or it could go the other way, like how we saw in Guinea and the other (worst-affected) countries.”

    What Guinea Bissau will struggle to cope with will be the already weak health system and limited number of medical experts and public health specialists.

    The concern over Guinea-Bissau’s ability to react to an Ebola case is not new, but has been heightened in the past week, following, for the first time in almost seven months, a cluster of cases just across the border in neighboring Guinea’s Boke prefecture, where traders cross daily to sell their wares and farmers come to work their fields.

    Violent protests in the northern Guinean town of Kamsar have also raised fears that aid workers will be impeded in their efforts to stop the virus crossing the border.

    The situation, should Ebola actually arrive, is particularly worrying as Guinea-Bissau is among the least developed countries in the world, according to the United Nations Human Development Index. More than 15 years after the end a year-long civil war, which displaced hundreds of thousands of people, the country still suffers from political instability, a fragile economy and poor infrastructure.

    The public health system is especially weak, with neither enough trained doctors and nurses, nor resources and supplies, to offer quality care during even regular times.

    There are just seven physicians per every 100,000 people, according to WHO. This is lower than the ratio of doctors that Guinea had before the outbreak began.

    “What Guinea-Bissau will struggle to cope with (should Ebola arrive) will be the already weak health system and limited number of medical experts and public health specialists,” Krishnan told IRIN. “Looking at the health facilities in Guinea-Bissau, when it comes to disaster preparedness and response, we should be on the higher side of caution, rather than taking it lightly.”

    Scaling up

    In light of the recent cases just across the border, organisations such as the International Federation of Red Cross and Red Crescent Societies (IFRC), WHO and Médecins Sans Frontières (MSF) have begun increasing their presence on the ground.

    “It’s no longer preparing for something that eventually will come one day,” said Youcef Ait Chellouche, IFRC’s Deputy Head of Regional Ebola Operations. “It’s now pushing up the level of preparedness. We call it ‘increased readiness for imminent risk’.”

    Chellouche said IFRC would be deploying additional staff to Guinea-Bissau this week to take part in social mobilisation campaigns in the border areas, including volunteers who worked in Liberia and Guinea. They also plan to train more local teams on how to safely put on and remove the Personal Protective Equipment (PPE) outfits, as well as educate both local authorities and communities about safe and dignified burials.

    If a case is identified in due time and isolated in due time, then the potential of containing the contamination is quite high. But if it’s late and if there is already contamination of other populations, it will be tougher.

    WHO says it has also sent community engagement experts to the border region to strengthen surveillance measures and early warning systems, two epidemiologists, and a logistician to make an inventory of available resources. It has also replaced more than 1,500 PPE kits that were lost in a recent warehouse fire. WHO says they plan to simulate outbreak-response exercises to test the actual level of preparedness to deal with an outbreak, but no date has been set.

    MSF has trained a six-person medical team of frontline workers, who will be among the first to respond if there is a suspected case. It has also prepositioned Ebola safety kits and set up a six-bed isolation unit in the Simao Mendes National Hospital, in Bissau, which has the ability to scale up its capacity to 24 beds if needed.

    “The biggest concern is to have even one case,” said the head of MSF’s West African unit, Stephane Doyon, who explained that Ebola can be difficult to contain even in countries with strong health systems. “If a case is identified in due time and isolated in due time, then the potential of containing the contamination is quite high. But if it’s late and if there is already contamination of other populations, it will be tougher.”

    The Portuguese government has also helped set up a laboratory, so that blood samples from potential cases no longer need to be sent elsewhere.

    Challenges remain

    Despite these recent efforts, it won’t be easy.

    Ebola response workers say they are worried about the potential of resistance among local populations.

    “I think the concern, or rather, the anticipated challenge, that we’d like to avoid – is the problems we had in other countries in which rumors and lack of clear information about Ebola led to more rumors and then community resistance against humanitarian service providers,” Chellouche said.

    Many locals told IRIN they still don’t know what exactly Ebola is or how it is transmitted.

    “Honestly, I don’t know what the symptoms of Ebola are,” said Bissau resident Samba Balde. “But I am scared because we border with Guinea Conakry, a country where the epidemic has arrived.”

    Donor funds are also lacking.

    “The way the world works today, it is not ready for disaster preparedness,” Krishnan said. “The world pays attention when the tolls starts going up. But unfortunately donors are not that forthcoming when it comes to boosting preparedness and resilience.”

    The authorities haven’t met even the minimum conditions to defend us against Ebola, even with support offered by international partners. They still need to do a lot more.

    MSF’s Doyen told IRIN that there have been regular meetings between the health ministry and partners to discuss Ebola preparation and response and that “there is good collaboration.” But if a case does arrive, he said the government “will definitely have a need for good support from the outside.”

    Less than six percent of Guinea-Bissau’s gross domestic product (GDP) is currently devoted to health care, according to WHO.

    But even with more outside help, many people in Guinea-Bissau say they have little faith it will be enough.

    “The authorities haven’t met even the minimum conditions to defend us against Ebola, even with support offered by international partners,” Bissau resident Ernest Higinio Correia said. “They still need to do a lot more.”

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    Why isn’t Guinea-Bissau ready for Ebola?
  • Killing us softly

    A recent public outcry in China, sparked by a damning documentary about air pollution, was based on well-founded fear:

    Of the 100 million people who viewed the film on the first day of its online release, 172,000 are likely to die each year from air pollution-related diseases, according to regional trends.* 

    Worldwide, pollution kills twice as many people each year as HIV/AIDS, malaria and tuberculosis combined,** but aid policy has consistently neglected it as a health risk, donors and experts say. 

    Air pollution alone killed seven million people in 2012, according to World Health Organization (WHO) figures released last year, most of them in low and middle-income countries (LMICs) in the Asia Pacific region.*** 

    In a self-critical report released late last month the World Bank acknowledged that it had treated air pollution as an afterthought, resulting in a dearth of analysis of the problem and spending on solutions. 

    “We now need to step up our game and adopt a more comprehensive approach to fixing air quality,” the authors wrote in Clean Air and Healthy Lungs. “If left unaddressed, these problems are expected to grow worse over time, as the world continues to urbanise at an unprecedented and challenging speed.”

    A second report released last month by several organisations – including the Global Alliance on Health and Pollution, an international consortium of UN organisations, governments, development banks, NGOs and academics – also called for more funding towards reducing pollution. 

    “Rich countries, multilateral agencies and organisations have forgotten the crippling impacts of pollution and fail to make it a priority in their foreign assistance,” the authors wrote. 

    Housebound in China 

    A dense haze obstructs visibility more often than not across China’s northern Hua Bei plain and two of its major river deltas. Less than one percent of the 500 largest cities in China meet WHO’s air quality guidelines. Anger over air pollution is a hot topic among China’s increasingly outspoken citizenry.  

    “Half of the days in 2014, I had to confine my daughter to my home like a prisoner because the air quality in Beijing was so poor,” China’s well-known journalist Chai Jing said in Under the Dome, the independent documentary she released last month, which investigated the causes of China’s air pollution.

    The film was shared on the Chinese social media portal Weibo more than 580,000 times before officials ordered websites to delete it

    Beyond the silo

    Traditionally left to environmental experts to tackle, the fight against pollution is increasingly recognised as requiring attention from health and development specialists too. 

    “Air pollution is the top environmental health risk and among the top modifiable health risks in the world,” said Professor Michael Brauer, a public health expert at the University of British Columbia in Canada and a member of the scientific advisory panel for the Climate and Clean Air Coalition, a consortium of governments and the UN Environment Programme. “Air pollution has been under-funded and its health impacts under-appreciated.”

    Pollution – especially outdoor or “ambient” air pollution – is also a major drag on economic performance and limits the opportunities of the poor, according to Ilmi Granoff, an environmental policy expert at the Overseas Development Institute, a London-based think tank. It causes premature death, illness, lost earnings and medical costs – all of which take their toll on both individual and national productivity.

    “Donors need to get out of the siloed thinking of pollution as an environmental problem distinct from economic development and poverty reduction,” Granoff said. 

    Pollution cleanup is indeed underfunded, he added, but pollution prevention is even more poorly prioritised: “It’s underfunded in much of the developed world, in aid, and in developing country priorities, so this isn’t just an aid problem.”

    Mounting evidence 

    Pollution kills in a variety of ways, according to relatively recent studies; air pollution is by far the most lethal form compared to soil and water pollution. 
     

    Microscopic particulate matter (PM) suspended in polluted air is the chief culprit in these deaths: the smaller the particles’ size, the deeper they are able to penetrate into the lungs.  Particles of less than 2.5 micrometres in diameter (PM2.5) are small enough to reach the alveoli, the deepest part of the lungs, and to enter the blood stream.  

    From there, PM2.5 causes inflammation and changes in heart rate, blood pressure, and blood clotting processes - the precursors to fatal stroke and heart disease.  PM2.5 irritates and corrodes the alveoli, which impairs lung function - a major precursor to chronic obstructive pulmonary disease. It also acts as a carcinogen.

    Most research looks at long-term exposure to PM2.5 but even studies looking at the hours immediately following bursts of especially high ambient PM2.5 (in developed countries) show a corresponding spike in life-threatening heart attacks, heart arrhythmias and stroke.

    Asia worst affected

    The overwhelming majority - 70 percent - of global air pollution deaths occur in the Western Pacific and Southeast Asia regions.  South Asia has eight of the top 10 and 33 of the top 50 cities with the worst PM concentrations in the world.  

     

    WHO says a city’s average annual PM levels should be 20 micrograms per cubic meter.  But cities such as Karachi, Gaborone, and Delhi have yearly PM averages above 200 micrograms per cubic meter. 

    The main source of PM2.5 in indoor air, or household air, is burning solid fuels for cooking and heating, using wood, coal, dung or crop leftovers - a common practice in rural areas of low and middle-income countries that lack electricity.  

    Almost three billion people live this way, the majority in the densely populated Asia Pacific region: India and China each hold about one quarter of all people who rely on solid fuels. For these people, the daily average dose of PM2.5 is often in the hundreds of micrograms per cubic meter. 

    Filling the gaps

    Unlike many other health risks air pollution is very cost-effective to address, Brauer said. Analysis of air quality interventions in the US suggests a return on investment of up to $30 for every dollar spent. 

    “We already know how to reduce these risks, as we have done exactly that in high income countries, so this is not a matter of searching for a cure - we know what works,” he said.

    But the World Bank report said that unless it starts gathering better data on local air quality in LMICs, the amounts and sources of air pollution and the full gamut of its health impacts, “it is not possible to appropriately target interventions in a cost-effective manner.”

    Granoff said there are also gaps in government capacity to monitor, regulate and enforce pollution policy. 

    Beijing hopes to bring PM2.5 concentrations down to safe levels by 2030, and has said it will fine big polluters. 

    The World Bank report said China is also charging all enterprises fees for the pollutants they discharge; establishing a nationwide PM2.5 monitoring network; instituting pollution control measures on motor vehicles; and controlling urban dust pollution.

    But enforcing environmental protections has been a longstanding problem in China.

    “Pollution policy will only succeed if citizens are aware of the harm, able to organise their concern [through advocacy campaigns], and have a responsive government that prioritises public welfare over the narrower interests of polluting sectors,” Granoff said. 

    While more people die from household air pollution than from ambient air pollution, the latter – through vehicles, smokestacks and open burning – still accounted for 3.7 million deaths in 2012, according to the WHO. 

    A change in the air

    Kaye Patdu, an air quality expert at Clean Air Asia, a Manila-based think tank - and the secretariat for the UN-backed Clean Air Asia Partnership, comprising more than 250 government, civil, academic, business and development organisations - said the aid community is finally starting to recognise the importance of tackling air pollution.  

    Last year’s inaugural UN Environment Assembly adopted a resolution calling for strengthened action on air pollution.  
    WHO Member States are planning to adopt a resolution on health and air quality at the upcoming World Health Assembly in May. 
    The proposed Sustainable Development Goals, which will set the post-2015 international development agenda, address city air quality and air, soil and water pollution. 

    None of the experts IRIN contacted could provide a breakdown of total aid spending on all forms of toxic pollution (air, water and soil pollution that is harmful to human health).  So IRIN asked each of the major global donors for their figures.  

    Three responded.  

    A back-of-envelope calculation of all reported spending on toxic pollution by USAID, the European Commission and the World Bank suggests that between them they committed about US$10 billion over 10 years. This does not include aid spending on the diseases that pollution causes. The World Bank’s spending figures eclipsed those of other the other donors. 

    By very rough comparison, HIV/AIDS, malaria and tuberculosis, with half the death toll of air pollution, received $28 billion via public sector commitments to the Global Fund – the world’s largest financier of programs that tackle these diseases – over the same period, a fraction of total spending on these diseases. 

    gh/ha/bp

    *Based on WHO statistics for per capita mortality rates in the Western Pacific region in 2012. 

    **The mortality figures for air pollution come from 2012 statistics and were released by WHO in 2014, while the figures for the infectious diseases come from 2013 statistics and were released by the Institute for Health Metrics and Evaluation in 2014 (the Global Burden of Disease study).

    ***Includes deaths from both household air pollution (4.3 million) and ambient air pollution (3.7 million): the combined death toll is less than the sum of the parts because many people are exposed to both. 

    For more: 

    The relationship between household air pollution and disease

    Ambient air pollution and the risk of acute ischemic stroke 

    Cardiovascular effects of exposure to ambient air pollution 

    Particulate air pollution and lung function  

    Long-term exposure to ambient air pollution and incidence of cerebrovascular events: Results from 11 European cohorts within the ESCAPE Project  

    OECD's The Cost of Air Pollution report
     

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    Killing us softly
  • Working to keep the peace: The impact of job schemes on ex-rebels

    Job-creation schemes are the traditional way to tackle the post-conflict problem of unemployed ex-fighters and to reduce the threat they can pose to peace and stability in fragile states.

    The theory - encapsulated in most demobilisation, disarmament and reintegration (DDR) programmes - is that jobs can be generated through training and capital inputs; that employment decreases the risks of re-recruitment; and once armed with a pay cheque, ex-combatants settle down and reintegrate more easily into society.

    Those assumptions were tested in a recent study exploring whether employment could reduce lawlessness and rebellion among high-risk men in Liberia. Of those who took part in the training scheme that was studied, 74 percent had fought in Liberia’s traumatic 14-year civil war.  The study concluded that training and cash incentives did encourage lawful employment, and as a result the men resisted being signed up by mercenary recruiters during a neigbouring conflict.  But there was no evidence employment improved their societal reintegration – they remained violent and anti-social.

    The NGO Action on Armed Violence (AoAV) works with ex-fighters and other troubled young men, typically involved in illegal mining and logging in remote “hotspots”, providing agricultural training and farm inputs. The income-generating scheme gave the researchers - Christopher Blattman of Columbia University and Jeannie Annan, of the International Rescue Committee - what they described as a unique opportunity to study employment-led rehabilitation.

    Their study found that even the highest risk men where “overwhelmingly interested in farming” as a result of the AoAV training. But although they spent 20 percent more time on farming, they didn’t abandon their illicit activities. Instead, they adjusted “their portfolio of occupations”, and saw a modest rise of $12 a month in earnings. Crucially the men reported “24 percent less engagement” with mercenary recruiters when Cote d’Ivoire’s short war erupted in 2011 – and none went to fight.

    The study’s findings were published in the Social Science Research Network.

    DDR employment programmes generally have a low success rate: Often the primary goal is to get a peace agreement signed, not sustained economic reintegration – a failing witnessed from the Central African Republic to the Democratic Republic of Congo.

    The study suggests that the single-trade focus of most DDR programmes fails to appreciate how, in the real world, the poor use multiple streams of income to mitigate risk. Liquid capital is key. The AoAV scheme demonstrated, almost accidentally, the power of cash incentives. As a result of a supply problem, roughly a third of the men expecting a second farm input installment were told to expect instead a cash payment – conditional on them not taking up mining or mercenary work. This financial inducement worked. 

    “The potential policy implication is that one-time transfers will not fully deter future criminal or mercenary opportunities. Ongoing incentives, such as cash-for-work programmes or other conditional transfers, could be important compliments,” the study noted.

    Despite the men’s relative economic success, the programme had “little effect on aggression, participation in community life and politics, or attitudes to violence and democracy” – in other words, little progress in terms of social integration. Furthermore, although AoAV’s intervention had a positive impact, an additional $12 a month earned was “not a high return” on the investment. 

    “Cost-effectiveness thus hinges on the hard-to-quantify social returns to lower crime and violence,” the study noted. In a fragile country recovering from conflict, that may well be a price worth paying.

    For further reading on DDR see:

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    101170
    How to help ex-rebels adjust to peace
  • Three words of advice for WHO Africa's new chief

    The World Health Organization says the number of new Ebola cases per week rose twice this month for the first time since December.

    This rise in incidence of new cases - if proven to be a trend - will be just one of the challenges facing WHO’s new regional director for Africa, Matshidiso Rebecca Moeti, as she attempts to overcome the multitude of criticism launched against WHO in recent months for its failure to act earlier and more competently during West Africa’s ongoing Ebola outbreak.

    “This is a critical moment for the WHO,” said Michael Merson, director of Duke University’s Global Health Institute. “It’s a real crossroads as to whether or not they’ll be able to reform and become an effective and efficient organization, particularly at the regional level.”

    Moeti, who officially took office 1 February, has vowed to make fighting Ebola WHO’s “highest priority,” while supporting countries to develop strategies to build up their health care systems, and reduce maternal and child mortality, tuberculosis, HIV/AIDS and non-communicable diseases.

    Many international observers say they have high hopes for Moeti, a medical doctor who has more than 35 years of experience working in the national and global public health sector. But she has a tough road ahead – particularly as the number of Ebola cases continues to rise, nearly a year after the outbreak was first declared.

    Here’s some advice from a few experts as Moeti begins her five-year term:

    1. Think Local

    Having competent and qualified staff on the ground, whose skills and expertise are matched to the needs of the country, is key to effectively implementing WHO policies and recommendations.

    “Everyone tends to discuss WHO at the global level and the regional level, but I don’t think this is where the problem lies,” said Fatou Francesca Mbow, an independent health consultant in West Africa. “It really lies in what the WHO is meant to be doing at country level. It is of no use to have very technical people sitting in Washington [D.C.] or Geneva, and then, where things are actually happening, [they become] politicians.”

    Mbow said that despite a wealth of technical documents being produced at headquarters, very often the staff from the field offices are appointed based on political motives. Country and field-level office meetings are often dominated by talk that, while politically correct, says “nothing of real meaning”.

    Staff reform at the local level will require both investing in employee development, including recruiting new and existing talent to the field offices, as well as making posts in “hardship” countries more attractive to the most qualified experts.

    “What often happens is that when people in-country are seen as being quite effective, they tend to get headhunted by the headquarters of the institutions that represent them,” said Sophie Harman, a senior lecturer in international politics at Queen Mary University of London. “So we see a type of brain-drain among people working in these sectors.”

    She said that improving salaries and offering more benefits, as well as taking into account what these people have to offer, could go a long way in incentivising them to stay at their field-level posts.

    “Good documents are interesting,” Mbow said. “But unless you have people at country level who understand them, who participate in writing them, who are able to implement them, who are passionate and committed to doing so, they’re just going to be reports.”

    2. Strengthen health systems

    There were many factors that contributed to the unprecedented spread of the Ebola outbreak, but inherently weak local health systems in the three most-affected countries meant that local clinics did not have the capacity, resources or expertise to handle even the smallest of caseloads.

    WHO must now work with local governments, partners and other on-the-ground agencies in all African countries to train and employ more doctors and nurses, implement universal health care coverage, and invest in better vigilance and surveillance measures.

    “I think the real test will be… how the WHO turns this outbreak into an opportunity to use our energy and thoughts and actions to build health systems that will not only help people [day-to-day], but will be able to respond to health crises like this in the future,” said Chikwe Ihekweazu, a managing partner of the health consulting firm EpiAfric.

    Increasing the number of health workers will be particularly important post-outbreak in Guinea, Liberia and Sierra Leone, where more than 400 health workers have died from Ebola, including some of the countries’ top doctors and nurses.

    “The WHO also needs to help minimise the knock-on effect that the Ebola outbreak is having on other health priorities in the region, such as HIV/AIDS and maternal health,” Harman said. “What we are seeing is that because of Ebola, people are afraid and so they are not accessing health facilities, which might actually reverse some of the many gains we’ve seen in the MDGs [Millennium Development Goals].”

    3. Rebuild credibility

    Despite WHO having, admittedly, acted much too late, both in terms of identifying the Ebola outbreak and then mobilizing resources to contain it – and losing much of its credibility in the process – experts agree that WHO remains a much-needed and relevant global health body, particularly when it comes to technical expertise.

    “We all recognize that the WHO has had a fairly good history in the past,” Ihekweazu said. “And while it was certainly criticized for its slow response at the beginning of the outbreak…the WHO is seen as the leading organisation that provides guidance for countries and I think…we are at a stage where [Africa] needs the WHO as a mutual partner who provides leadership for the continent going forward.”

    Mbow agreed: “What I would say is that when you are criticised, take the blame fairly, but don’t lose sight. And don’t lose confidence in the resources you do have to offer.”

    Restoring donor confidence in WHO will be particularly important, as the regional office for Africa has the largest budgetary needs, the most countries, and, in many ways, the most challenging health problems to deal with.

    “No one wants harm done to the WHO,” Merson said. “We will be a much better, healthier planet, if the WHO is strong and effective… But it is never going to have a huge budget and so I think its strengths should be in standard-setting, norm-setting and providing the best technical sound advice in health that countries need.”

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    101153
    3 tips for WHO's new director for Africa
  • Who celebrity advocates are really targeting. And it’s not you.

    This week was a fanfare for celebrity humanitarians: Forest Whitaker appealed for peace in South Sudan alongside UN Under-Secretary-General for Humanitarian Affairs Valerie Amos; Angelina Jolie opened an academic centre on sexual violence in conflict with British Member of Parliament William Hague; and UNICEF Goodwill Ambassador David Beckham launched an initiative for children. 

    In recent years, aid agencies have increasingly used celebrity advocates to raise awareness and money for their causes. There’s just one snag: 

    It doesn’t actually work. At least not as much or in the ways we think. 

    According to research by Dan Brockington, a professor at the University of Manchester, public responses to celebrity activism are surprisingly muted. His work is the first quantitative research on the subject. 

    “Using celebrities for broader outreach, for reaching mass publics and attracting media attention is absolutely not the silver bullet it appears to be,” he told IRIN on the sidelines of a 6-8 February conference at the University of Sussex, where he presented research recently published in the book Celebrity Advocacy and International Development.

     

     
    In a survey he conducted with 2,000 British people, 95 percent of respondents recognized five or more of 12 charities listed to them, including the British Red Cross, Save the Children UK and Oxfam UK. But two-thirds of the respondents did not know a single “high-profile” advocate of any of the NGOs (In this case, music executive Simon Cowell and singers Victoria Beckham and Elton John respectively, among many others). 

    The realpolitik might not be that pleasant. But you'll achieve your goals. 

    Focus groups and interviews with more than 100 “celebrity liaison officers” and other media staff at NGOs further reinforced his findings. 

    What’s more, Brockington says, those who pay attention to celebrities do not necessarily know which causes they support. 

    “People who follow celebrities often do so because they are not political,” he said during the interview. “They are fun, light. You want to live their lives…[People] don’t engage with [celebrities] for the more worthy things.”  

    Celebrity stardom flat-lining 

    Despite the rise in the use of celebrity advocates (which, by the way, dates back to at least Victorian times), the mention of charities in broadsheet and tabloid articles about celebrities only increased ever so slightly between 1985 and 2010, according to a separate study by Brockington. “There has also been a decline in the proportion of newspaper articles mentioning development and humanitarian NGOs at all,” the study found. 

    The perception that celebrities engage the public in the first place may itself be overstated. 

    After a steady rise in coverage of celebrities in the British press over two decades, the percentage of articles mentioning the word celebrity (only a fraction of total articles about celebrities) stopped increasing around 2006 and is now hovering at about four percent of all articles studied, the research found, validating the findings of earlier studies on the same subject (The study looked at The Guardian, The Times, The Independent, Daily Mail, The Mirror and The Sun). 

    The magazine industry’s own statistics show a tapering off of readership in recent years after steady growth.

    Celebrities can be successful in engaging the public – Miley Cyrus made waves last year when she sent a homeless man to pick up her MTV Video Music Awards; Bob Geldof’s charity single on Ebola quickly rose to the top of the charts; and celebrity-driven telethons like the UK’s Comic Relief are generally quite successful. Leonardo DiCaprio’s speech at the opening of the Climate Summit 2014 garnered nearly 2 million views on YouTube – far more than many of the heads of state who also spoke at the summit.

    And the effectiveness of celebrity advocacy in non-Western contexts, which is much less studied, could well be higher. UNICEF, for example, uses more national than global celebrity ambassadors because they often resonate better with local audiences. Social media campaigns can also be extremely successful in some instances, though “not a game-changer”, according to Brockington (For a cold shower on this topic, see Paul Currion’s column on why KONY 2012 may have engaged the public, but ultimately failed).

    Influence without accountability 

    But on the whole, at least in the UK, public interest in celebrity appears to be lower than most people think, Brockington says. But the belief in star power - inaccurate as it may be - lingers: In his survey, 74 percent of respondents said they thought other people paid more attention to celebrities than they did. Statistically, this cannot actually be true, but it proves an important point: If people think that other people care about celebrities, it can become a self-fulfilling prophecy.

    Brockington found that while celebrities may not be as successful as we think in engaging the public, they are still successful at engaging politicians and decision-makers. 

    Why? 

    Because politicians - like most people - like being around celebrities. But also because politicians – also like most people - believe that celebrities express populist sentiment, even though, in fact, they often don’t. So they grant them access and influence. 

    Ben Affleck, for example, has briefed US Congress about the Democratic Republic of Congo and George Clooney has addressed the UN Security Council about Darfur.   

     

    For the small but growing number of academics studying the subject, the gap between celebrity advocacy and public engagement raises a major ethical question: If celebrities wield all this power and influence, yet do not represent popular sentiment, who are they accountable to?  

    “The celebrity is not beholden to his or her public in the same manner as the elected official,” writes Alexandra Cosima Budabin, of the University of Dayton, in an upcoming book: Celebrity Humanitarianism and North-South Relations. “Misguided proposals and ineffective interventions will not endanger a celebrity, whose position is assured by both financial and political elites.”  

    Celebrities’ increasingly powerful voices on issues of humanitarian aid, poverty reduction and famine has allowed them to “often decide for the suffering receivers” and eliminate public scrutiny and debate, according to Ilan Kapoor, a professor at York University in Canada and author of Celebrity Humanitarianism: The Ideology of Global Charity. 

    “…Mostly unelected, private individuals and organizations have, for all intents and purposes, taken over what should primarily be state/public functions,” he writes

    A Machiavellian approach?

    Perhaps even more interestingly, Brockington found in his interviews with staff of NGOs with celebrity advocates that liaison officers know the impact on the public is limited, but use celebrities anyway because they can access and influence not the general public but decision-makers. 

    “The realpolitik might not be that pleasant,” he told the University of Sussex conference, “but you’ll achieve your goals.”

    UNICEF’s announcement of a new initiative for children by its Goodwill Ambassador David Beckham may reflect a clear understanding of this precise point. It reads: “David will use his powerful global voice, influence and connections to raise vital funds and encourage world leaders to create lasting positive change for children,” the statement said. 

    Malene Kamp Jensen, of UNICEF’s Goodwill Ambassador Program – one of the first and largest of its kind, acknowledges that sending a message to policy-makers is a “very, very important role” of celebrity ambassadors: “They do have certain access and platforms.” 

    But she says it is important to engage all segments of society: “You communicate to as many people as possible… I don’t think you can just say: ‘Forget the public; let’s lean on the policy makers. It’s very much a collective effort.” 

    For Jeffrey Brez, of the UN’s Messenger of Peace Programme, the target audience depends on the specific goal in that instance. 

    “Is there a treaty about to be ratified and you need a few extra votes? Is it a humanitarian crisis and you need a bump of visibility to help Congress push through appropriations for humanitarian aid? There are so many moments when they can come in and give you a little boost. It depends … what you’re trying to achieve.”

     

    Celebrity advocacy "industry" 

    Brez and Jensen both challenge the suggestion that celebrities are seen to be a silver bullet to public engagement, insisting they are just one tool in the toolbox. 

    “We’re always looking just to incrementally move the needle,” Brez says. But he complains that he and his colleagues lack real research to assess just how much impact their outreach has. 

    When Project Runway All Stars shot its Season Finale at UN Headquarters, 2 million fashion fans – not the UN’s traditional audience – were exposed to its work in a positive light. But how much did they retain? Did their perceptions of the UN change? 

    Brockington cautions not to read too much into his findings: celebrity advocacy can work, he says, but must be used strategically, for example to influence elites or fundraise among existing supporters. 

    But he says celebrity liaison officers are themselves frustrated by their NGO colleagues’ expectations that if they just throw a celebrity at something, the organisation will be instantly successful at captivating the public imagination. 

    Could the bubble eventually burst if more people become aware of the limits of celebrity advocacy? Unlikely, Brockington says, given what has now become a celebrity advocacy “industry”, in to which NGOs invest a lot of time and resources.  

    “There is a fair bit of smoke and mirrors in this… [but] a lot of people are vested in this. They want it to work. There’s all sorts of strong collective interests in sustaining it.”

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    Does celebrity advocacy actually work?
  • After Ebola: What next for West Africa’s health systems

    As rates of Ebola infection fall in Guinea, Liberia and Sierra Leone, planning has begun on how to rebuild public health systems and learn lessons from the outbreak.

    Nobody is declaring victory yet. But in Sierra Leone, the worst-affected country, there were 117 new confirmed cases reported in the week to 18 January, the latest statistics available, compared with 184 the previous week and 248 the week before that. Guinea halved its cases in the week to 18 January – down to 20 – and Liberia held steady at eight. 

    The epidemic is not over until there are zero cases over two incubation periods – the equivalent of 42 days. “It’s like being only a little bit pregnant – there’s no such thing as a little Ebola. We have to get to zero, there can be no reservoirs of Ebola,”  Margaret Harris, spokesperson of the World Health Organization (WHO), told IRIN. 

    But after 21,724 cases and 8,641 deaths in nine countries since the epidemic began in Guinea last year, there is some light. And health workers are already starting to look at what’s next. “Right now important meetings are going on in each country to work out what needs to be done to rebuild - in some significant respects to build health systems almost anew - and to build back better,” said Harris. 

    A European Union donor conference is due at the beginning of March in Brussels. “What we want to see as a country is a resilient health system that can withstand shocks,” Liberia’s Assistant Health Minister Tolbert Nyenswah told IRIN. “Our plan [to be presented in Brussels] will be finalized by the end of February. It will be well costed with tangible goals.”

    Ebola tested the public health systems in the three West African countries to near destruction – most places in the world would have also struggled. But where the three failed was at the basic “nitty-gritty” level of “standard surveillance, testing and monitoring, the containment of cases, the bread and butter of public health”, said Adia Benton, a social anthropologist at Brown University in Rhode Island.

    Citizen and state

    A successful malaria campaign in Sierra Leone last week, which reached 2.5 million people, and a planned polio and measles vaccination programme in Liberia, are positive signs for the health services. But the list of necessary reforms is long: stronger surveillance; healthcare that will work after the international partners leave; access to affordable services. The list must also embrace longer-term structural changes, including the relationship between citizen and state.

    According to Antonio Vigilante, Deputy Special Representative for the Consolidation of Democractic Governance in the UN Mission in Liberia, and Resident Coordinator, “there is a golden opportunity to have a different start, to have a more balanced development that leaves outcomes in the hands of the people. It’s a very delicate stage, full of opportunities, which should not be missed.”

    Liberia is one of the world’s poorest countries and Ebola has been a tragic addition to the burden. It has destroyed livelihoods; already dizzying rates of unemployment have worsened; and food prices have soared. Both rural and urban communities are suffering.

    Vigilante is worried the economic impact of Ebola, and the interruption of immunization and reproductive health services during the crisis, could put more people at risk than the virus itself did. “A number of [social protection] measures in the recovery phase would need to be universal,” he said. One example would be if Liberia scaled up its pilot Social Transfer Programme, launched in 2009, to provide just US$40 per year to two million children. There would be sizeable “knock on effects on local markets and entrepreneurship” at minimal cost, according to the Washington-based Centre for Global Development

    Lesson learned: “Community, community, community. Engagement, engagement, engagement”

    Schools are due to re-open on 2 February in Liberia, and a strong case could be made for a universal school feeding programme to attract and retain children in class. “Even before Ebola many children were out of school,” UNICEF spokesman in Liberia, Rukshan Ratnam, noted.

    Money matters

    But will the donors come to the party? Donors pledged $1.5 billion to a UN coordinated appeal for Ebola last year, but $500 million is still unpaid. “If we cannot close that funding gap we will snatch defeat from the jaws of victory. It’s as simple as that,” Bruce Aylward, WHO assistant director-general in charge of the Ebola response, told reporters on 23 January. 

    Wasted dollars can be expected in a crisis when the priority is effectiveness - stopping the outbreak - rather than efficiency in how the money is spent. That equation will change if Ebola does not come roaring back with the rains in April, and donors begin to look at competing needs.

    There is potential to re-purpose Ebola infrastructure - some of it now idle with a glut in treatment facilities - if donors are willing to be flexible, said Vigilante. Laboratories used for testing could be incorporated into national laboratory services; some of the more permanent treatment units could be re-launched as community-based health facilities; contact tracers could be used as community mobilizers. 

    “We certainly lost staff as a result of Ebola. But the converse of that is there was a very rapid upskilling as people were trained to work in the treatment units or as contact tracers. It’s a group we should build on,” said Harris. “It’s really important we don’t lose them in the transition to a normal service.”

    Local heroes

    Among the lessons learned across the region has been the importance of consulting, engaging and empowering local communities: their lack of trust in central government was a major handicap in tackling the epidemic. “Community, community, community. Engagement, engagement, engagement,” said Harris. “We need to listen more. We need to do a lot of work with sociologists and anthropologists.”

    Liberia in particular has a highly centralized system of government, but local communities have emerged as critical players in the response with a new can-do attitude. “People given a chance can do a fantastic job,” said Vigilante. 

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    101046
    After Ebola
  • Nice and dirty – the importance of soil

    Be it laterite, loam, peat or clay, soil is life. It's the foundation of food security, and so the UN has declared 2015 as the year to draw attention to the stuff.

    As much as 95 percent of our food comes from the soil, but 33 percent of global soils are degraded, and experts say we may only have 60 years of nutrient-rich top soil left - it is not a renewable resource. 

    Africa is especially hard hit. Land degradation denudes the top soil, shrinking yields and the ability of the earth to absorb harmful greenhouse gases. In sub-Saharan Africa, an estimated 65 percent of agricultural land is degraded. That costs the continent US$68 billion a year, and affects 180 million people - mainly the rural poor, already struggling to eke out a living.  But better land management practices could deliver up to $1.4 trillion globally in increased crop production. 

    So how to implement sustainable policies that protect the food security of future generations? The uptake of sound soil management approaches is currently low. Farmers are under pressure to abandon effective traditional methods in favour of practices that deliver quicker, short-term, returns. 

    Further reading on the issue
     2015 – International Year of Soils
     FAO Soils Portal
     Agriculture for Impact
     The Comprehensive Africa Agriculture Development Programme
     AGRA
     United Nations Convention to Combat Desertification
     Africa Soil Information Service

    But a report - No Ordinary Matter: Conserving, Restoring, and Enhancing Africa’s Soils - released in December 2014, points to potential pathways. These include combining targeted and selected use of fertilisers alongside traditional methods such as application of livestock manure, intercropping with nitrogen-fixing legumes or covering farmland with crop residues. The goal is an ambitious - if contradictory sounding - “Sustainable Intensification” of agriculture.

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    Nice and dirty – the importance of soil
  • Universal health coverage - Ebola reveals the gaps

    West Africa's Ebola epidemic has cruelly exposed the weaknesses of health systems in the countries where it struck. It was understandable that they were not prepared for Ebola, which has never been reported in the region before, but the director of the World Health Organization (WHO), Margaret Chan, says what they lacked was a robust public health infrastructure to deal with the unexpected.

    “This requires good background data on the usual,” she says, “so that the unusual stands out. [It means] making good quality care accessible and affordable to everyone, and not just to wealthy people living in urban areas; having enough facilities available in the right places with enough well trained staff and uninterrupted supplies of essential medicines; diagnostic capacity that returns rapid and reliable results; and information systems that pinpoint gaps and direct strategies and resources towards unmet needs.”

    Chan was speaking on what had been designated as the first Universal Health Coverage Day (on 12 December), setting out an ambitious check-list for health systems which can cope with whatever is thrown at them. This is clearly a challenge in any developing country, but much more of a challenge in fragile states like those currently affected by Ebola. 

    It could be SARS next time

    Nick Hooton is a research, policy and practice adviser with the ReBuild Consortium which works on how to strengthen health systems in post-conflict states. He told IRIN that although research still had to be done, the post-conflict environment was almost certainly a reason why the disease spread so fast. “Undoubtedly the systems are very poor,” he says, “and the staffing levels are very low, but there are also subtler factors at work, issues about trust and things like that. This is a disease which has been well controlled in other places, and yet got massively out of control. If you look at the DRC [Democratic republic of Congo] and northern Uganda, there is no great supply of health professionals there either. So we are talking about things like a breakdown in the links between the communities and the public services which take a long time to build up again.”

    Hooton stresses that addressing these underlying weaknesses is crucial: “It's Ebola this time, but it could be SARS next time, or some other disease. There is absolutely a need for a disease response - Ebola is a horrible disease and it is out of control - but to stamp out the disease and leave the systems as they were is not doing any favours to anyone.”

     

    " To stamp out the disease and leave the systems as they were is not doing any favours to anyone "

    The Millennium Development Goals, now reaching their end date, set their health targets for particular sectors, maternal and child health, or for specific diseases - TB, malaria and HIV/AIDS. This approach had the advantage of providing measurable targets, and was able to attract donor funding, but didn't work on the kind of system-wide resilience that Margaret Chan is talking about. Now, with negotiations in full swing for the post-2015 goals, there is a chance to move from the single-sector, “vertical” strategy to a broader based, more “horizontal” approach.

    David Heymann, the head of the Centre on Global Health Security at Chatham House, says we need to look at what has happened in the past. “In the past there has been an international treaty, the International Health Regulations, which clearly states that 194 countries have agreed to strengthen their core capacities in public health. Countries were left to evaluate themselves on whether or not they had attained these goals, and they were to have completed their core capacity strengthening by 2014.

    “But what happened? I'll be a little tough here by saying that donor agencies didn't provide funding through the international health framework; they didn't bother to provide funding unilaterally to these countries, and international organizations didn't bother to try to enforce this treaty which 194 countries have signed. So we're back to zero. And now we have to start over again.”

    Using the vertical to measure the horizontal

    The demand for measurable outcomes is always going to favour single disease interventions over the less dramatic, more mundane strengthening of health systems, but Heymann says we just have to figure out how to incorporate one into the other. “We have to use some of those issues as indicators for universal health coverage. If you can accomplish community treatment for HIV or tuberculosis through a system, and you can hook other systems into that, that's universal health coverage. Let's use the vertical to measure the horizontal.”

    Of course, it all takes money, and the discussion on universal health coverage on 12 December at the London School of Hygiene and Tropical Medicine produced vigorous debate on the merits of various types of financing.

    Anne Mills, the deputy director of the London School, set out what she sees as the ground rules: “The core principle of universal health coverage is that people contribute according to their ability to pay, and benefit according to health need. A good financing system needs to be equitable - richer groups should contribute more than poorer groups. Secondly, it needs to put minimal reliance on payment at the point of use; payment needs to be collected in advance. And thirdly, financing should be pooled as much as possible and not segmented into many different pools for different population groups.”

    Mills pointed out that a lot of health systems in Africa, for instance, are far from achieving this, with as much as 48 percent of health costs in Kenya, 66 percent in Nigeria and 76 percent in Sierra Leone being paid by the user at the point of use, which bears very heavily on the poor.

    The UK's own health service is funded from general taxation and is free at the point of use, so it was perhaps not surprising that the dominant sentiment in the London debate was in favour of the public financing model.

    Health economist Robert Yates has worked on these issues for the UK's development ministry, DFID, and for WHO. He told IRIN: “The key is compulsory and publicly governed financing, either through taxes, or through compulsory social insurance payments. You have to have richer people paying more and with voluntary insurance. If you leave it to the market, the market will always try to give lower premiums to healthier people, and charge higher premiums or exclude those who need it more. This is why voluntary systems always, always fail. Even community-based health insurance, which sounds great, has never worked anywhere.”

    An intensely political process

    Yates is scathing about past attempts by the likes of the World Bank to encouraged developing countries to switch to privately financed systems, with people taking out insurance or paying out of their pocket when they need care. This, he says was a terrible mistake, resulting in weakened health systems, especially in Africa. But he sees some positive changes happening, in Thailand, Latin America and most recently Indonesia.

    “You find that when countries make the transition to middle-income status,” he says, “they have the resources to move towards a publicly funded system, but it doesn't happen naturally. To force the rich and the healthy to cross-subsidize the sick and the poor is an intensely political process. But then some smart politician recognizes that universal health coverage would be very popular with the masses, and it's wonderful when you see this starting to happen.”

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    Ebola reveals health system gaps

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