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Global Connections – March, 2008
Newsletter Contents
Overview of this issue
With the anniversary of the U.S. invasion of Iraq around the corner, we wanted to take time in this issue to consider war’s impact on a nation’s health. From the huge financial cost, to civilian deaths and injuries, to psychological trauma, to the destruction of health infrastructure, war inflicts damage beyond military casualties—damage that lasts for decades.
HAI’s new program in Cote d’Ivoire is one small part of that country’s recovery process from more than five years of internal conflict. We are excited to share with you the beginning stages of our joint efforts with the Ministry of Health to rebuild the health care system and improve testing and treatment for HIV.
As always, feel free to visit our web site, contact us, or make an online donation to support our work. (And now you can also find HAI on Facebook!)
Update on Timor-Leste
On February 11, 2008, President Jose Ramos-Horta sustained multiple gunshot wounds in an assault on his residence which saw rebel leader Alfredo Reinado killed. Reinado originally came to prominence amid the deadly unrest on Dili’s streets in 2006. Prime Minister Xanana Gusmao escaped a separate but coordinated ambush on the same day unharmed. While the government has declared a state of emergency and imposed a nightly curfew, the streets of the capital city of Dili have remained calm since the incident. The HAI office was closed only briefly the day of the event. All HAI staff are safe and our work with the Ministry of Health is moving forward in support of improved maternal and newborn health in the country.
Rebuilding together: HAI’s new program in Côte d’Ivoire
Côte d’Ivoire, once considered one of the most stable and prosperous countries in West Africa, is emerging from more than five years of internal conflict. As in Mozambique and Timor-Leste when Health Alliance International began its programs, the conflict has destroyed public infrastructure and drained resources from health, education and other needed services. HAI is working with the Ministry of Health and other NGOs to strengthen the health system and further the process of rebuilding.
From prosperity to civil war to fragile peace: Côte d’Ivoire’s recent history
Source: BBC News Côte d’Ivoire’s first president, Felix Houphouet-Boigny, came to power after independence from France in 1960 and stayed in office until his death in 1993. Subsequent political power struggles, including a coup in 1999 and a failed election in 2000, increased tensions that were exacerbated by falling prices of Côte d’Ivoire’s main exports of coffee and cocoa, and the exploitation of ethnic differences between the Christian south and seat of political power and the Muslim north.
An uprising of northern troops in 2002 led to several years of internal war, followed by a fragile U.N.-monitored peace that was punctuated by protests and violence. Abidjan, the major southern port city and economic capital of Côte d’Ivoire, became more crowded as people fled from the north. Fighting destroyed public infrastructure such as hospitals, schools and banks throughout the north, and particularly in Bouaké, the seat of the northern opposition forces.
The Ouagadougou Peace Accord of March 2007 established a power-sharing agreement between north and south, beginning a process of reunification. U.N. troops have committed to remain in Côte d’Ivoire until elections can be held mid-2008. People are returning to the north, but the region has changed.
Health and HIV today
War and conflict lead to deaths both directly and indirectly, as another article in this issue discusses. In addition to fatalities due to combat, Ivorians living in the north suffered from a lack of basic necessities: food, clean water, health care. According to one report, up to 70% of the health facilities in the north were non-functional in the aftermath of the civil war. The shortage in the north is even more severe than in the country as a whole: there are only 0.12 physicians and 0.6 nurses for every 1,000 people in Côte d’Ivoire, which combined are well below the threshold of 2.3 health professionals per 1,000 people used by the World Health Organization (WHO) to define a critical health workforce shortage.
“During the war, most of the health personnel left Bouaké and health centers were closed,” recalls Atta Kouassi Bamba, a member of the HAI staff in Côte d’Ivoire. “People had to buy medications from street vendors, which can be expired and very dangerous. In addition, there were no qualified health care workers left in Bouaké to perform complex medical procedures, which in a situation of war can also have serious consequences.”
Health indicators in Côte d’Ivoire show the toll that conflict has taken. UNICEF reports a decline in life expectancy from 52 in 1990 to 46 in 2005, which is even lower than the 49 years that Ivorians could expect to live in 1970. Under-5 child mortality has similarly spiked again to 195 deaths per 1,000 live births after declining to 157 in 1990. According to the WHO, there are about 690 maternal deaths for every 100,000 live births. Almost 11% of the population lives in extreme poverty on less than $1 a day. UNAIDS estimates that about 7% of adults are infected with HIV.
Several NGOs have stepped in to fill the gaps in basic health care and HIV treatment during the conflict, and the advent of PEPFAR funding in 2003 brought even more NGOs. Absent a centralized oversight mechanism—much less a functioning health care system—to manage these numerous efforts, HIV services were often fragmented or duplicative. The Ministry of Health (MOH) recognizes the critical need to rebuild the national health infrastructure to provide primary health care as well as respond in a coordinated, comprehensive way to a growing HIV burden.
First steps: prevention of mother-to-child transmission of HIV
HAI has a long history of working in Côte d’Ivoire. Since 1991, HAI Executive Director Steve Gloyd and his wife Ahoua Koné have provided technical assistance to the Central University Hospital in Bouaké, to the National Institute of Public Health in Abidjan, and support to the hospital of Gagnoa in collaboration with Rotary clubs. Ahoua grew up in Bouaké and her family still lives there.
In early 2007, HAI began working with the MOH and local partners including UNICEF to help strengthen the national HIV/AIDS response through an integrated program of testing and prevention of mother-to-child transmission (pMTCT). To date, HAI has launched the pMTCT pilot program in seven of fifteen targeted health centers in Bouaké, with the goal of expanding to additional sites outside of Bouaké by the end of 2008.
HAI staff in Côte d’Ivoire: (front row, right to left) country director Dr. Wisal Hassan, A. Bamba, A. Yao; (back row) R. Yao, Dr. B. A. Bakor, Dr. A. Dionkounda Several staff from HAI’s other programs in Mozambique and Sudan have moved to Bouaké to support the work in Côte d’Ivoire. Along with several Ivorian staff members, HAI’s new team is able to apply best practices in health system strengthening and scaling up ARV treatment to this project.
Dr. Beteck Albert Bakor used to work for HAI in Mozambique and is now a clinical advisor in Côte d’Ivoire. “In Mozambique, HIV scale-up poses a challenge in that the chronic care model has to be integrated in the routine activities of health systems,” notes Dr. Bakor. “In Côte d’Ivoire we have the double challenge of organizing the health system and at the same time integrating HIV scale-up. We are optimistic though, because there are factors here that favor scale-up: motivated human resources and some infrastructure that survived the conflict.”
HAI staff are working with MOH staff, including doctors, nurses and midwives, to establish protocols for HIV counseling, testing and treatment for women who come to the health centers. The first step in HIV testing is counseling on the possible outcomes and options. Until now, health centers have had to send tests out for analysis and wait two days to two weeks in some cases for results. This lag time meant that many women never returned to the health center for their results, or returned only to be told they would have to come back again later.
The “drop-off” of women from one step in the process to the next—from getting the test to hearing the results, or from hearing the results to getting enrolled in an HIV care and treatment program—can be significant, and is dangerous particularly for pregnant women who are at risk of transmitting HIV to their babies during pregnancy, delivery, or infancy. Lack of drug availability at the health centers due to problems with the supply chain is another challenge to adherence once women are on an ARV program.
To improve the rate of women learning their HIV status, HAI and the MOH are focusing on making HIV testing a routine part of prenatal visits and implementing rapid testing on-site, so women learn the results in 30 minutes rather than days or weeks later. HAI is also working with the MOH district directors to improve the flow of medications from the central pharmacy out to the health centers. Health centers are beginning to offer support groups and counseling programs to decrease stigma and improve adherence for those on antiretroviral therapy (ART).
Looking ahead
HAI and the MOH next hope to turn their focus to building the capacity of the regional referral hospital in Bouaké to provide additional testing and perform CD4 counts, which determines when an HIV-positive person is at the stage to begin ART. HAI is also seeking additional funding to broaden the programs to include pediatric and adult treatment, as well as integrate the local tuberculosis clinic with the health centers and HIV services.
As the government and communities continue to rebuild, HAI looks forward to working closely with the MOH to strengthen health services and provide a full range of care for everyone, including pregnant women and their families.
The impact of war on public health
War is, as the World Bank asserts, “development in reverse.” In the 20th century alone, approximately 200 million people were killed by war, or the equivalent of more than two-thirds of the U.S. population. Given the ubiquity and carnage of war, it is critical to understand the linkages between militarism and health, and in particular U.S. policy and its role in global conflict.
Historically, war and militarism have been key impediments to expanding public health systems and improving living conditions in the countries in which HAI has worked, including Mozambique, Timor-Leste, Côte d’Ivoire and Sudan. Violence—armed conflict and militarism—in these regions has resulted in displaced populations, crippled health and social infrastructures, and reallocation of scarce resources to weapons procurement and defense budgets, among other thing. Coupled with economic violence, such as sanctions and unsustainable debt burdens, war has devastating short- and long-term impacts.
Iraqi children swim in water polluted by a destroyed septic system. (Photo: Gerri Haynes)War and conflict not only cause death and destruction; they also have real and severe impacts on factors critical to ensuring good health outcomes. Health service delivery systems break down due to lack of resources and the death or flight of the health workforce. Conflict-related disruptions reduce access to clean water, sanitation, and food, resulting in malnutrition and increased mortality among children and other vulnerable populations. Other impacts include increased rates of poverty, decreased rates of education, and increased levels of economic disparity and national debt.
In the face of such effects, countries emerging from war face enormous barriers to rebuilding broken health systems. A central piece of HAI’s guiding philosophy has been supporting countries’ efforts to emerge from conflict and war through health systems-strengthening and capacity building, solidarity, and advocacy work. During the South African-orchestrated war in Mozambique, HAI participated in solidarity efforts to support communities that were directly affected by the conflict by sending medicines and supplies to those in need. Post-conflict, HAI worked side by side with the Ministry of Health to support rebuilding the severely damaged health infrastructure in Mozambique’s central region.
Similarly, HAI began to support primary care service work in Timor-Leste before independence. After Timor-Leste gained independence, HAI’s programs have been directly affected by the recurrent political crises and turmoil. The population has continued to suffer violence and widespread fear that restricts progress. HAI also has new programs in Côte d’Ivoire to help rebuild the conflict-damaged health care infrastructure and attract health care workers back to the Bouaké area. In both countries, HAI’s work has been based on the belief that a strong, peaceful society needs a strong, functional health system and healthy citizens.
Non-governmental organizations are often called upon to deal with the effects of war, but the complex task of preventing war is more difficult and requires the participation of a larger global community. War has very few “winners” and civilians are the biggest losers. A recent article published by the Harvard International Review estimates that approximately 90 percent of war casualties by violence are civilians—handily euphemized as “collateral damage” in mainstream media.
Report from Physicians for Human Rights on the health costs of the war in IraqThe ongoing war in Iraq, for instance, has produced an enormous number of victims and “losers.” These include the estimated “654,965 excess deaths related to the war” of Iraqi civilians (Lancet, 2006); the Iraqis who survive and have to rebuild their fragmented country; the countless U.S. soldiers returning home who struggle with serious mental health problems and other disabilities; and the U.S. public that is left to deal with a war that has cost close to $500 billion to date but is expected to ultimately top $2 trillion in costs to U.S. taxpayers.
The direct effects of war and militarism on populations throughout the Global South are a tragedy. They are compounded by the diversion of resources required to fight wars such as those in Iraq and Afghanistan, limiting the amount available for public health and other critical social services at home and abroad. This speaks to a larger truth: war doesn’t just end. The consequences last for decades. HAI’s work with countries’ health sectors to rebuild infrastructure and communities attempts to mitigate those consequences, while our advocacy efforts in collaboration with other organizations must be directed at preventing conflict from starting.
Advocating for Change
Health Alliance International supports and is involved in a number of initiatives related to global health equity and justice and we urge you to add your support. For more information or to get involved contact Emily deRiel by or by phone at (206) 543-8382.
Current initiatives:
PEPFAR reauthorization. In late February, the House Foreign Relations Committee approved legislation to reauthorize the President’s Emergency Plan for AIDS Relief (PEPFAR) for another five years. The new bill will fund the program for a total of $50 billion, which is $20 billion more than President Bush proposed and which represents an actual expansion of the program rather than a stagnation of funding. Significant victories in this reauthorization bill are the removal of the requirement that one-third of all funds go toward abstinence programs (the “abstinence-only earmark”), and increased funding for women’s health and health workforce strengthening efforts. The legislation is awaiting consideration by the House, and a similar $50 billion reauthorization bill was introduced last week in the Senate as well. For more details and to track progress, visit the Library of Congress search engine and look for H.R. 5501 and S. 2731.- Code of conduct for international NGOs to support health workers and health systems. HAI and a number of other international NGOs have developed a code of conduct that aims to improve the way that NGOs work in order to strengthen the capacity of countries’ public health systems. The draft Code is currently published on the web and is open for comments. It will also be presented and revised through a series of meetings in 2008. The first meeting was held in early March in Kampala, Uganda, at the first Global Forum on Human Resources for Health. Read and comment on the Code online at ngocodeofconduct.org, or for more information contact .
- Macroeconomic literacy training – coming in June! Inspired by a training organized by ActionAid International USA in Washington DC, HAI will host a training to increase macroeconomic policy “literacy” on June 19-20, 2008. The training will provide a basic understanding of the effect of International Monetary Fund (IMF) policies on health and social services budgets in developing countries. If you are interested in learning more about this topic or would like to attend the training, contact .