Category: APHA IH Section

In 2015, tuberculosis killed on average 34,000 people per week, a total of 1.4 million deaths.  This is just one of many facts published in a report by the WHO that brings renewed attention to one of the world’s oldest diseases.  Roughly a third of the world’s population – 2 to 3 billion people – are infected with tuberculosis, though only a small proportion (5-15%) will develop an active infection in their lifetime.  Sixty percent of new tuberculosis infections occur in only 6 countries: India, Indonesia, China, Nigeria, Pakistan, and South Africa.

As is a theme in much of medicine, a strain of drug-resistant tuberculosis is affecting people around the world.  Multi-drug resistant tuberculosis, or MDR-TB, cannot be cured with the two most common TB drugs.  In 2014, 480,000 people developed MDR-TB with over a third of patients (190,000) dying.

The road to recovery from tuberculosis requires a 6-month drug regimen.  When not followed or completed, drug resistant forms occur and can be transmitted person-to-person in highly concentrated areas, such as prisons, or among people living in poverty.   For patients with MDR-TB, treatment is grueling, involving at least 18-months of second-line drug treatment and isolation.  Those who suffer from MDR-TB face social stigma and isolation as well as side-effects from the cocktail of treatment, including hearing and vision loss, chronic pain, and mental illness.

When we take the pills, we feel worse. I’m losing my hearing a little. I feel pain in my bones, in my whole body.

– Maria Smolnitcaia (52-year-old woman living with MDR-TB in Balti, Moldova)

While 6 countries bear the brunt of new tuberculosis infections, the former Soviet Union leads the pack in cases of MDR-TB.  Moldova, a small country at the crossroads of Eastern Europe and Central Asia, has one of the highest rates of MDR-TB in the world at 18% of new TB infections.  Sixty-five percent of tuberculosis re-infections are MDR-TB.

There are several reasons for the prevalence of MDR-TB in these formerly Soviet states.  Analysis of tuberculosis bacterium links surges in incidence to social upheaval, such as that seen during the collapse of the Soviet Union in the 1990s.  A breakdown in healthcare infrastructure made it difficult for people to follow a sufficient antibiotic course to fight the disease.  MDR-TB in the UK has steadily risen, reaching 81 cases in 2012, and has been traced to the same event.

An extensive prison system has also been blamed for the development and spread of MDR-TB.  Russian prisons prior to 2001 had a tuberculosis infection rate of 7,000 per 100,000 prisoners.  The close quarters of prison are the perfect breeding ground for MDR-TB, which then permeates the community when an infected prisoner is released.

Tuberculosis is the leading cause of death for people living with HIV. Due to a weakened immune system, people with HIV are 26 to 31 times more likely to get TB than the general population.  These facts are doubly worrying when considered with the prevalence of latent tuberculosis infections among healthcare workers.  A study published in PLOS One found that 47% of healthcare workers in 7 low-income countries had a latent infection, ranging from 37% in Brazil to 64% in South Africa. By definition, latent tuberculosis is not contagious, but once infected, an active infection can occur at anytime and be transferred to a patient.  In India, this is troubling as there is no mechanism to reduce the spread of tuberculosis in hospitals:

Therefore, anecdotally, there’s a lot of TB among doctors and nurses, even drug resistance and some mortality.  Hospital staff are vulnerable two ways — because they are in India, a hyper endemic country with half of adults already infected [with latent TB], plus hospitals collect TB patients so staffs are at risk of infection.

– Jacob John, virologist and retired professor from the Christian Medical College, Vellore, India

As cited by WHO and the New England Journal of Medicine, antiretroviral therapy in concert with tuberculosis treatment can significantly improve outcomes and longevity for both diseases. Sadly, concurrent treatment is lacking as reported by WHO.  In 2015, 1.2 million people living with HIV contracted tuberculosis.  Of that number 390,000 received treatment for both diseases.  An equal number died.

The Sustainable Development Goals are committed to end tuberculosis by 2030, ensuring healthy lives and well-being for all.  What next steps need to be taken to eradicate a disease as old as the human race?

On September 25, 2015, the UN General Assembly adopted the Sustainable Development Goals (SDGs) to be completed by 2030.  Seventeen goals with 169 targets fall neatly within a framework of People, Planet, Prosperity, Peace, and Partnership.

To estimate the likelihood of reaching these goals in the next 14-odd years, it is helpful to evaluate the shortcomings of the SDGs’ predecessor.  Established in 2000, the Millennium Development Goals (MDGs) consisted of 8 goals to be achieved by 2015.  Called the “most successful anti-poverty movement in history,” the MDGs made inroads in reducing global poverty, but there is still much to do.

A literature review finds that the MDGs were more favorable to wealthy countries, which for all intents and purposes had met or exceeded the 8 goals prior to inception.  In the development stage, only 22% of member parliaments were involved. Others argue that the MDGs ignored local and governmental capacity in poorer countries and limited policy growth by narrowing focus.  Rather than setting goals realistic for each country’s individual baseline and capacities, the MDGs ‘ghettoize the problem of development and locates it firmly in the third world.’  The final limitation of the MDGs speaks to issues of data collection and surveillance in developing countries.  Reliance on national averages and aggregated data ignored the world’s poorest, meaning they would be the last to benefit.

A video recently released by WHO’s YouTube page culminates with the sentiment “The world needs better health data and ICD is delivering it.”

The ICD or International Classification of Diseases allows global users to share health information about mortality and morbidity.  ICD counts deaths as well as diseases, injuries, symptoms, reasons for encounter, factors that influence health status, and external causes of disease.

ICD is less useful and utilized in developing countries.  In the least developed countries, health records, including birth and death records, are not well recorded and may be based on second-hand information or less scientific means such as verbal autopsies.  Is the ICD accessible to developing countries, ostensibly the same countries who share the largest burden of poverty and disease?  What are the fundamental gaps in data collection and utilization that must be ratified before progress is observed?

One of the first steps to usable data is the census.  A timely, accurate census is the foundation for public health policy and development:

Census data can, for example, highlight sex-ratio imbalance, identify trends in migration, fertility, nuptiality and population ageing. Such information is the bedrock of almost all aspects of human, social and economic development. It helps governments determine the number of schools, hospitals or highways to be constructed, or the kind of programs that should target young and older people, as well as women. Censuses thus contribute to reducing poverty, ensuring sustainable development and supporting reproductive rights and gender equality.

The United Nations Population Fund provides technical and financial support to assist developing countries with census efforts.  When a developing country conducts a census, the results can be unexpected.  Afghanistan’s 2010 census – its first since 1979 – found lower fertility rates and higher contraceptive use than anticipated.  In very remote areas, there is limited data to base projections on, such as in areas of Myanmar where there was no reliable data even on total population.

The 2030 Agenda is built on the assumption that every country will be able to identify and locate the most vulnerable groups, but over 109 countries in the world today don’t have vital statistics and registration. We still need to develop better ways to reach those who have historically gone uncounted.

– Dr. Babatunde Osotimehin, UNFPA Executive Director

Without accurate census information, are we putting the proverbial cart before the horse?

Note: This was cross-posted to my own blog.

Seven years after it dismissed initial complaints against the South Korean Ministry of Justice’s (MOJ) policy of mandatory HIV and drug tests for foreign English teachers, the National Human Rights Commission of Korea (NHRCK) has (finally!) recommended that the MOJ remove the testing requirement. NHRCK’s recommendation follows the decision of the UN’s Committee on the Elimination of Racial Discrimination (CERD) in May 2015, which stated that the MOJ’s policy requiring a health check which includes HIV and drug tests for native-speaking English teachers (those on the E-2 visa) constitutes racial discrimination.

The complaint which led to the ruling, filed by a teacher from New Zealand against the Ulsan Metropolitan Office of Education, was initially submitted to the NHRCK in 2009 when the testing policy was first implemented. Unfortunately, the commission dismissed it, along with 50 others protesting the policy, and cancelled its initial plans for a public hearing on the grounds that they were not willing to hear cases on individual complaints. (You can read more about the NHRCK’s decision and the events leading up to it in a paper (PDF) by Ben Wagner, the human rights attorney who filed the case on the New Zealand teacher’s behalf.) In dismissing the complaints, however, the commission allowed the case to be taken to the CERD, where it was accepted in 2012.

Now the commission has formally backed the CERD’s ruling, which – despite the fact that it took seven years to get there – is a big win on the topic. HIV is a forgotten disease (PDF) in South Korea and is incredibly stigmatized, which makes it easy for government agencies like the MOJ to codify this kind of direct discrimination without any public outrage or pushback from within the country. In this sense, the challenge to this ongoing affront to human rights from an authoritative domestic institution is crucial. In particular, the commission’s decision calls out the MOJ’s policy as blatant racial discrimination, specifically citing the fact (also noted in the CERD’s decision) that the tests have no basis in the protection of public health because both Korean nationals and non-citizen ethnic Koreans are exempt from the testing requirement:

[T]he Ministry of Justice takes a stand that an independent state is bestowed with wide discretion in its immigration control and, in particular, such tests are indispensable as the instructors are supposed to protect young students and facilitate a safe environment and public health.

However, as noted by the CERD, even the vast discretion embedded in immigration control hardly renders it reasonable that while Korean teachers and ethnically Korean foreign language instructors are exempted from the testing, only foreign E-2 visa holders are under an obligation to test for HIV. Likewise, the concerns about a safe public health environment offer little ground for different treatment between ethnically Korean teachers and foreign instructors with E-2 visas.

Second, it points out that the policy has the potential to stigmatize foreigners as being high-risk for HIV and thus lead the general public to believe that they are not at risk for infection. This is important, as the country’s HIV infection rate continues to climb.

The MOJ never responded to, or changed its testing policies in response to, the UN CERD’s ruling. Hopefully the Korean government will be more responsive to a ruling from a domestic institution, but there is no way to know for sure. However, foreign English teachers now have a resource to challenge the testing if they wish. The NHRCK decision explicitly states that the UN CERD decision carries the same authority as domestic Korean law:

Article 6 (1) of the [Korean] Constitution states, “Treaties duly concluded and promulgated under the Constitution and the generally recognized rules of international law shall have the same effect as the domestic laws of the Republic of Korea,” indicating that the country has a legally binding obligation to facilitate the rights prescribed by the treaty to which it agrees by means of accession, ratification or succession. Article 26 of the Vienna Convention on the Law of Treaties stipulates, “Every treaty in force is binding upon the parties to it and must be performed by them in good faith,” while Article 27 states, “A party may not invoke the provisions of its internal law as justification for its failure to perform a treaty.”

English teachers may be able to use the CERD decision to persuade their employers not to require the HIV test; alternatively, they have the option to file a complaint with the NHRCK (either named or anonymous) and/or the UN CERD Secretariat. The full decision has been made available by Matt von Volkenburg on Gusts of Popular Feeling.

Shameless plug: I will be presenting on this topic, including successes and ongoing advocacy initiatives, at this year’s APHA Annual Meeting in Denver.

With less than a month till the U.S. Presidential election, UN High Commissioner for Human Rights Zeid Radd al Hussein has taken a stand against Donald Trump, calling him a threat to international affairs:

If Donald Trump is elected on the basis of what he has said already – and unless that changes – I think it is without any doubt that he would be dangerous from an international point of view.

The High Commissioner isn’t alone. The Economist‘s Intelligence Unit ranked a Trump presidency sixth on their list of global threats, just after jihadi terrorism destabilizing the global economy.

The Economist might have a point. Trump has made numerous comments that indicate that neither health nor human rights will be prioritized in his administration’s foreign policy:

I would bring back waterboarding and I’d bring back a hell of a lot worse than waterboarding. (Republican Presidential Debate, ABC News 2016 )

What I won’t do is take in two hundred thousand Syrians who could be ISIS. (Face the Nation, CBS – 2015)

This is reinforced by the unusual cadre of suspect world leaders (read: perpetrators of human rights abuses) that he has singled out for praise, including Kim Jong-eun, Saddam Hussein, and Vladimir Putin.

At the moment, Trump is all talk. However, should he be elected and even one of his portentous assertions be made manifest, both health and human rights – which in many cases are inextricably linked – will be imperiled. Here is a look at how Trump might influence health at home and abroad.

Sexual assault
In 2013, Trump dismissed the U.S. military’s atrocious sexual assault record on Twitter in his usual style:

26,000 unreported sexual assaults in the military-only 238 convictions. What did these geniuses expect when they put men & women together?

What Trump’s tweet fails to grasp is that more than half of reported military sexual assault victims are men.

Like the perpetrators of these assaults, Trump struggles with issues of consent. Even if we ignore recently surfaced audio of Trump boasting about inappropriately grabbing women or comments made about women consciously and unconsciously flirting with him, Trump has a history of hiring men with dubious ideologies and records. His own private council and a top executive at The Trump Organization, Michael Cohen, recently stated that women cannot be raped by their husbands, in response to decades-old allegations by Trump’s first wife. Ahead of his September 26th presidential debate, Trump was advised by Roger Ailes, former Fox News chairman who was fired by the network amid sexual harassment allegations. As President, Trump would appoint more than 6,000 federal positions, including top officials for all federal agencies.

Reproductive rights
Abortion in the US was legalized in 1973, in part to reduce the public health toll of illegal abortions especially as they impacted low-income women. Shortly after legalization, deaths and hospitalizations due to unsafe abortion practices significantly decreased. However, access to abortion is constantly challenged in the States, through measures such as Texas’s recently-defeated HB2 and legislation that puts restrictions on the administration of medication abortion. Thirty-seven states require prescription of the dual dose by a licensed physician, while 19 others require that a licensed physician be physically present when the medications are taken. As the scope of reproductive rights grow slimmer, what American women need is a champion, not a leader whose basic understanding of female anatomy is that they bleed out of their “wherever.”

Trump (despite describing himself as “very pro-choice” when he flirted with a presidential run in 1999) appears to be prepared to encourage the erosion of this ever-embattled constitutional right: in a town hall meeting in March, he voiced his support for the criminalization of abortion and stated that women who seek them should face “some sort of punishment.” He quickly backed down from this extreme position in response to public backlash (even from those within his own party), but his potential ability to appoint up to four Supreme Court justices creates the specter of encroachment on women’s rights. At a time when reproductive choice is finally beginning to see some forward movement around the globe in countries such as Poland and the Philippines. If US law heads in that direction, it could embolden other countries to go the way of Northern Ireland.

Religious discrimination
Trump has taken a hard line on his views of the world’s Muslim population. Besides proposing a ban on Muslims entering the U.S., Trump suggested that all Muslim-Americans be tracked through a surveillance system. Many drew comparisons to Nazi Germany, but in an interview with George Stephanopoulos, Trump justified his proposal by saying it was no worse than the internment of Japanese-Americans under the purview of Franklin D. Roosevelt . A report by the Commission on Wartime Relocation and Internment of Civilians found the internment camps “were motivated largely by racial prejudice, wartime hysteria, and a failure of political leadership.”

War and war crimes in the Middle East
War is a guaranteed human rights catastrophe, and the devastation that armed conflict wreaks on public health infrastructure and health systems is myriad and far-reaching. In addition to the direct destruction of hospitals and killing, often directly and intentionally, of health workers, war and conflict can reverse decades of progress toward eradicating diseases – as evidenced by the recent reemergence of polio in conflict zones. US military activity has been responsible for much of this kind of damage in the Middle East. Iraq’s healthcare infrastructure may never fully recover from the first Gulf War in 1991 and the subsequent 2003 invasion. As it stands, nearly 97% of Iraqi families have no health insurance, and even if they do there are only 7.8 doctors per 10,000 patients, a rate miniscule in comparison to neighbors such as Jordan and Lebanon. Personal safety and security are the top reason physician recruitment and retention in this country is so difficult, according to Médecins sans Frontières (MSF). Additionally, Syria and Yemen are humanitarian tragedies due to ongoing American coalition-funded proxy wars.

Adding nuclear weapons to the mix hardly seems imaginable, but Trump seems to have a bit of a trigger finger when it comes to nuclear weapons. On a morning news show, Trump said that he would never rule out the use of nuclear weapons against ISIS, citing “unpredictability” as a central theme of his foreign policy agenda.

The candidate has also advocated the murder of terrorists’ families, which, as John Oliver helpfully reminds us, is a war crime:

The other thing with the terrorists is you have to take out their families, when you get these terrorists, you have to take out their families. They care about their lives, don’t kid yourself. When they say they don’t care about their lives, you have to take out their families.

Trump has indicated that he is willing to compel servicemen and women to do this and commit other war crimes, such as torture detainees:

They won’t refuse. They’re not going to refuse me. If I say do it, they’re going to do it.

These statements (and many more) have been made – in public fora and broadcasts – since Trump announced his presidential bid 485 days ago. The American voter can only speculate what other dubious position statements will emerge in the scant weeks leading up to election day. Is Trump a threat to global health and human rights? That is a personal call each voter will have to make on November 8th.