APHA opposes Trump move to cut essential WHO funding

Washington, D.C., April 14, 2020 – The American Public Health Association stands in solidarity with the World Health Organization and denounces the Trump administration’s decision to halt U.S. funding. Ending U.S. contributions to WHO will cripple the world’s response to COVID-19 and could harm the health and lives of thousands of Americans.

“WHO is in a race to treat, test and protect people from the devastation of COVID-19. Its leadership in combatting COVID-19 has been indispensable, irreplaceable and decisive,” said Georges C. Benjamin, MD, APHA’s executive director.

“Getting ahead of this virus requires a rapid global response and the coordination of multiple countries,” Benjamin said. “It is only with this coordination that we can accelerate the pace of research and generate the critical science-based evidence that is needed to save the lives of people in the U.S. and around the world.

“We must be singularly focused on using all of our assets, including WHO, to get in front of this insidious virus.”

WHO’s work is critical for:

  • Creating a comprehensive research and development agenda to get safe vaccines and effective therapeutics in play. A WHO-led approach allows multiple countries to work together to accelerate the pace of research and development and increase the amount of what can get done.
  • Addressing the next frontier of the pandemic, which will devastate low-resource countries and humanitarian settings. While more than 70% of the world remains underprepared to prevent, detect and respond to such public health threats, WHO has been working with low-income countries for to help them prepare. Strong, effective and functional public health systems within countries are crucial for reducing risks.
  • Leading the U.N. development system’s public health work at the country level. WHO works with vital operational arms of the United Nations, including UNICEF, the World Food Program and UNHCR. Though U.S. assistances is essential to aiding these countries, funding is still insufficient.
  • Supporting and coordinating supply chains for critical public health commodities, such as personal protective equipment and lab kits. WHO is the lead of the U.N. COVID-19 Supply Chain Task Force for the global procurement of pandemic commodities. The U.S. is purchasing its own supplies, but if all countries did so on their own, prices would skyrocket everywhere. Bulk purchasing will help everyone.

“Now is not the time to undermine WHO’s vital work,” Benjamin said. “There will be a time for lessons learned once this pandemic is over. WHO has expressed a full willingness to participate in a thorough review of what has worked and what has not as we have raced to stop this disease, and we support their inclusion.

“Any effort to remove funding from WHO, particularly in this time of crisis, would be a crime against humanity and endanger the health of Americans and people around the world.”

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The American Public Health Association champions the health of all people and all communities. We are the only organization that combines a nearly 150-year perspective, a broad-based member community and the ability to influence federal policy to improve the public’s health. Learn more at www.apha.org.

Rising to the Emerging Global Health Challenges in 2020

By: Dr Yara Asi

Dr Asi was featured in the most recent Section Connection newsletter. To learn more about Dr. Asi please click here.

An interview with Dr. Aisha Jumaan, founder and president of the Yemen Relief and Reconstruction Foundation, and Dr. Samer Jabbour, professor at the American University of Beirut, co-chair and convener of the ‘Lancet-AUB Commission on Syria: Health in Conflict’, and founding Chair of the Global Alliance on War, Conflict, and Health.

Earlier this year, the World Health Organization released their predictions for the urgent health challenges of this new decade. To any public health professional, many of these challenges aren’t new: climate change, conflict, health equity, consumer protections, and infectious disease and epidemics, to name a few. At the most recent APHA Annual Meeting in Philadelphia, dozens of panels and presentations covered these very issues. However, because of the interlinkages between all these health threats at the local, national, and global levels, it is not enough to simply be able to name these threats. The real challenge is building the global coalitions with the resources to tackle these complex problems. While the membership of APHA certainly can’t accomplish this alone, the level of expertise within the organization on dealing with these issues, including within the International Health section, provides an excellent foundation for the research, advocacy, and practice that is necessary to tackle these complex risks.

The International Health Section Luncheon at the 2019 Annual Meeting featured two speakers who are working on the leading edge of some of these threats to public health. Dr. Aisha Jumaan, founder and president of the Yemen Relief and Reconstruction Foundation, and Dr. Samer Jabbour, professor at the American University of Beirut, co-chair and convener of the ‘Lancet-AUB Commission on Syria: Health in Conflict’, and founding Chair of the Global Alliance on War, Conflict, and Health, spoke of the challenging conditions that the world’s most vulnerable people face in accessing their most basic health needs. I talked with both of them after the meeting to get their thoughts on international health and what the members of APHA can do to support health practices, advocacy, and research that responds to the needs of fragile populations.

Due to their combined decades of experience, I first asked them what they have learned about international health in their work. Dr. Jabbour first reminds us of the difference in one’s approach to international health depending on their country of origin. As someone living and working in Beirut, to him international health “is not an ‘external’ subject or a field.” He emphasized, however, that the overall goodwill, commitment, and meaningful work happening in international health is vital in reducing global health equities and that this is an important support to count on for the countries that need to make the greatest progress. The importance of the local approach was supported by Dr. Jumaan. “Training 10 professionals outside Yemen and then having them conduct training in Yemen to a higher number of beneficiaries with a small budget have resulted in a multiplicative impact for our work…these local professionals have a better access to the countries we work in and are trusted by the local communities.”

Dr. Jumaan reiterated this perspective when I asked about the largest challenges to international health. She cited the lack of connection between the agencies that provide funding as well as the recipients of much of the funding with the environments where they are actually implementing projects. “We need to engage the beneficiary communities in every step of the way in planning and implementing international health projects.” Of course, many practitioners and researchers in this field agree with this sentiment and have for decades, but without fundamental change in how the major international health organizations operate, it is difficult to imagine these various interests coalescing around the types of widespread solutions needed to deal with the challenges presented by the WHO. Dr. Jumaan found localization efforts to be the most significant change that the international community could make going forward, with powerful institutions and associations doing the work of empowering local professionals to care for their own populations and supplying technical support when necessary.

Dr. Jabbour was clear in his response to what the largest priorities of the international health community must be going forward: “Pay more attention to political determinants of health, particularly war and conflict, contribute more meaningfully to climate change, including through engaging with the younger generations who are now leading the fight, and work towards more equitable economic systems, everywhere.”

What can we do, as members of one of the largest public health associations in the world? Aside from research and advocacy, Dr. Jumaan emphasized the need to provide technical assistance and mentoring to professionals within countries we want to support. The skills of the IH section of APHA could help “develop the skills of these professionals to implement public health projects that address the local needs in a cost-effective way.” Dr. Jabbour saw the strong potential of APHA to serve as a “beacon for public health,” but in terms of tackling the hardest public health problems, he found it vital to “take a hard decision, make the commitment, start talking with partners, draw up plans, and get seriously engaged.”

As the world’s eyes are freshly poised on global public health, we can remember Dr. Jabbour’s directive in our own work. What is the question that no one is asking? Where is the population that needs representation and outreach? How can APHA leverage its considerable institutional and scholarly resources to show solidarity with our fellow public health professionals around the world? We will need these global alliances to tackle the public health threats that are known, like war, climate change, and poverty, and those yet to come, as our global vulnerability to infectious disease is once again being made apparent with the coronavirus. Especially for practitioners and researchers in stable or more developed nations, our colleagues like Dr. Jabbour and Dr. Jumaan that are working on the frontlines of global health emergencies are counting on us for our time, energy, and engagement. As this new decade begins, let us ensure that we rise to these impending challenges and preserve health and well-being for all.

31,285 Human Rights Violations and Counting: Hypocrisy in America’s Liberal Bastion

On February 8, 2019, city councilors in Los Angeles met to approve a resolution declaring LA a “city of sanctuary.” It was hailed as a victory amid growing political tension and derision, a “symbolic welcome sign,” according to Councilman Gil Cedillo, that was supposed to “set the tone for the way we want our residents to be treated.” However, for the 31,285 Angelenos who are experiencing homelessness, Los Angeles is anything but a sanctuary.

You know you’ve stumbled into LA’s Skid Row the moment you arrive. Trash clings to the streets in heaps, stacked haphazardly against rows of tents so densely packed it’s difficult to find the sidewalk. It’s a stark contrast to the dazzling city skyline that frames the neighborhood. This isn’t a part of Los Angeles you can see from the sterile aerial shots that punctuate film and television, but it’s the reality of a county with over 10,000,000 residents and wage growth that can’t keep up with the rising cost of living.

Everyone in Los Angeles, from City Hall to residential streets, agrees that more must be done. Inevitably, however, most attempts to build temporary or permanent supportive housing in Los Angeles is met with public resistance. NIMBY, the acronym for “Not in My Back Yard,” refers to the opposition of development in one’s own neighborhood, even if they would otherwise support such a project somewhere else. NIMBYism is rampant in LA’s complex and powerful network of neighborhood associations and councils. When city officials met with residents of Sherman Oaks, a wealthy neighborhood on the west side of the city, to show proposals for homeless housing projects, residents turned out in force to oppose the plans. One resident went so far as to propose his own solution to the need for emergency shelters in Los Angeles:

“You want me to have compassion for people who don’t care about themselves?…I’m proposing maybe you build a reservation for these homeless somewhere out in the desert…when we interned the Japanese during the Second World War, we didn’t intern them in the city”.    

Much of this resentment and stigmatization comes from the deeply held American belief in the “prosperity gospel.” In other words, those who work hard and are free from vices are protected against material scarcity. Homelessness, then, is a personal failing and not a societal one. It’s time we reframe homelessness.

Public officials, public health professionals, and advocates across Los Angeles need to change the way we talk about homelessness to end the rampant NIMBYism in the city. It’s time to adopt a rights-based approach that focuses on the systemic failures that are determinants of homelessness. We need to abandon the “treatment first” approach to combating homelessness, where we attempt to fix the precipitating effects of inadequate housing (substance abuse, mental illness, poor health) before providing stable housing. Instead, programmatic and policy efforts should focus on “housing first” approaches that satisfy basic human needs before attempting to solve complex behavioral and lifestyle issues. The model is evidence-based and, unlike many interventions designed to combat homelessness, it’s effective. Investments in housing first approaches reduced homelessness by 91% in Utah, and research efforts in Seattle show that the savings generated by reducing the need for crisis intervention services more than makes up for the cost of housing first projects.  

Image Credit: The Spotlight

Los Angeles has the opportunity to lead by example in a world that is growing increasingly less empathetic to the plight of the vulnerable. However, we cannot be the city that birthed the “Me Too” movement and turn away from the fact that half of all women who are homeless report that they are domestic violence survivors. We cannot say that we are a city that believes that black lives matter when we know that while only 8% of LA County identifies as black or African American, they make up over one-third of the unsheltered population. It is unconscionable that our city turns out in force for Pride but fights efforts to house homeless youth, nearly half of whom cite whom they love as the reason they are homeless.

In December, Los Angeles hosted the UN’s celebration of the 70th anniversary of the Universal Declaration of Human Rights, a document that states in no uncertain terms that housing is a right of every person everywhere. If we are to be taken seriously in our defiance of increasingly discriminatory national rhetoric, we must do better here at home.

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
-UDHR, Article 25.1

Read more about evidence based messaging campaigns around homelessness.

The Man-Made Health Crisis in Yemen Cannot Wait for the End of the War: What Can Humanitarian Actors Do?

In 2017, only a few years into a brutal civil war, Yemen reported a cholera outbreak of one million cases, more than half of which were children, making it the worst outbreak in history. At the time, Yemen was already in the midst of what was considered a dire humanitarian crisis, with more than 20 million citizens affected. A year later, the situation has become even more critical, with the United Nations warning of “the worst famine in 100 years” within the next few months if the war continues. Many more Yemenis have died from lack of access to basic needs, such as clean water, food, medical care, and sanitation, than fighting.

Yemen was already considered one of the poorest countries in the world before the war, with low rankings on all indicators of human development. However, the war has completely devastated the nation and the health of its citizens. Multiple outbreaks of infectious disease such as cholera and malaria, high rates of food insecurity and malnutrition, tens of thousands of trauma-related injuries, and widespread mental distress have exhausted the healthcare system. Almost 80% of Yemeni children reported symptoms of post-traumatic stress disorder, an exceedingly high rate even when compared to other conflict-affected nations. Healthcare workers, many of whom have been unpaid for months or years, have been kidnapped, harassed, and killed, while hospitals have been directly attacked and bombed. Medical facilities are left with barely functional equipment, empty supply shelves, and sometimes no medical staff at all. One article detailed how the grandmothers of an infant born four months premature brought him to a hospital where they found no physicians, who had all walked out in protest the previous day after one of them was beaten up by one of the hospital guards. The grandmothers attempted to place the infant into an incubator themselves, but both machines were broken.

In April 2018, as long-term wars in Syria, Iraq, Afghanistan, and South Sudan rage on, as a probable Rohingya genocide in Myanmar goes into its second year, and as natural disasters strike with increasing frequency and strength around the world, United Nations Secretary-General António Guterres called Yemen the world’s worst humanitarian crisis. The International Rescue Committee reports that 16 million people (almost three quarters of the country’s population) cannot access basic medical care, with more than half of the country’s already limited health facilities destroyed. What is left of the health system is Yemen is almost entirely sustained by contributions of medicines, supplies, and money by international donors. An estimated 9.5 million people were provided some form of medical intervention by the WHO and their partners in 2017 alone. However, the politics of the conflict have rendered even this emergency care inconsistent and unreliable. Médecins Sans Frontières (MSF) has occasionally had to cease providing services in some parts of the country due to sustained attacks on their facilities and staff by both Houthi fighters and Saudi warplanes. An intermittent Saudi blockade on Yemen’s ports has prevented humanitarian agencies from bringing in food, medicines, and fuel, and even when supplies can enter the country, distribution networks are insecure due to airstrikes and combatants. Like many of the world’s worst humanitarian crises, the devastating circumstances are almost entirely man-made. It is not lack of money or resources that has brought Yemen to this point- the entirety of the budget that the Yemen Ministry of Health proposed for 2018 amounts to just three days of what Saudi Arabia alone spends on the war campaign.

Yemen would not be the first country to see the health and well-being of its citizens used as a bargaining chip in an intractable conflict. Alex de Waal, a professor at Tufts University and the Executive Director of the World Peace Foundation, called these types of man-made famines and humanitarian emergencies “economic war,” which is much more difficult to classify under international humanitarian law than a violent bombing campaign or overt starvation tactics. “The coalition air strikes are not killing civilians in large numbers but they might be destroying the market and that kills many, many more people,” he told The New Yorker. Couple destroyed markets with ruined medical facilities and it is clear that the quality of life of human civilians will be devastated for the long term. This is by no means a new wartime strategy. Perpetrators try to bring their enemy -combatants and civilians who are in any way affiliated with them- to the brink of humanitarian desperation to force concessions.

What is needed is immediate and meaningful action on the part of the actors involved in the war as well as the international community that is both providing the weapons and aid that sustain the conflict. Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, outlined three requests to ease the humanitarian burden in the country. First, he called for guaranteed safe access throughout all of Yemen so that aid agencies can provide goods and services. Second, he demanded an end to all attacks on health workers and facilities. Lastly, he insisted that civilian health workers who remain in Yemen must be paid for their vital services. Similarly, a report by the International Peace Institute recommends that the international community, especially the UN Security Council, enforce compliance to international humanitarian laws and norms. Humanitarian actors must also work to coordinate their responses by sharing data, involving local stakeholders, and collectively pushing against blockade efforts. While meeting immediate needs is the clear priority, prevention and long-term health capacity building must also be pursued to both avert widespread catastrophe and prepare for the Yemen that will remain after the war ends. None of these actions must wait for a political end to the war, which is the only way to truly protect civilian life and ensure basic access to the human rights of food, water, sanitation, and health. However, these actions can push back against efforts by all sides of the conflict to use the health and well-being of Yemen’s citizens as pawns in the achievement of their aims.

 

Public Health and Migration

Throughout history humans have been on the move, migrating due to famine, war, persecution, and to find a better life. In a new age of “zero tolerance” policies and deeming humans “illegal” it is important to understand that how global policy defines someone matters.

There are many terms for populations that are fleeing disasters and we have to understand globally accepted terms for populations on the move.

    1. Asylum-seekers are people “whose request for sanctuary has yet to be processed”. Every nation has their own asylum system to determine who qualifies for protection and how they request this protection. If the petition for protection does not meet the host country’s criteria the individual may be deported to their home country.
    2. Internally displaced people have not crossed any borders to seek safety but have moved to another location within their home country seeking safety or shelter.
    3. Refugees are people who are forced to flee their home country in order to seek safety from conflict or persecution. This group of people are protected under international law and are not to be sent back to the situation where their safety is at risk.
    4. Migrants are people who choose to move for work, education, family unification, etc. These people can go back to their home country and continue to be protected by their home country government.
    5. Undocumented migrant is a person who has entered a country without proper documentation, or their immigration status expired while in the host country and they have not renewed their status, or they were denied legal entry/immigration into their host country but have remained in the host country.
    6. Statelessness is someone who does not have a nationality. Individuals can be born stateless or become stateless due to nationality laws which discriminate against certain genders, ethnicities, or religions, or the emergence or dissolving of countries.

These international definitions are important, because it determines if, how, and when the international community can respond to crisis situations. A large caveat is that due to national sovereignty under international law a nation must request that international organizations like UNHCR provide international assistance to these particular communities. If nations do not request assistance or reject assistance then these populations are left without any sort of protection leaving them vulnerable and isolated, as seen with Syrian refugees in Lebanon. The international community has also seen the inhumane treatment of people seeking protection to include isolated detention on islands such as is currently used in Australia.

No matter how the international community defines these populations, they face poor health outcomes due to disease, economic stress, and trauma. Examples include:

  • An increase in child brides among Syrian and Rohingya refugee populations. This in turn affects infant and maternal mortality rates as well as the woman’s future economic prospects.
  • Malnutrition of both mother and child leading to increased death rates for children under five and stunting of growth in children that survive. This is currently being seen in Yemen.
  • Decreased breastfeeding rates due to maternal stress, disease, and separation from familial groups/support systems. An increase in breastmilk substitutes in refugee or displaced persons camps is also an issue that goes against international humanitarian policies.
  • During the Mediterranean refugee crisis the international community witnessed large groups of people risking their lives on overfilled boats that often sank, causing large scale loss of life. These refugees then faced xenophobia, closed borders, and detention upon their arrival.
  • Currently in the United States there has been an increase in detaining families and child migrants from Latin American countries for an indeterminate amount of time. Organizations like American Academy of Pediatrics have begun to discuss long term effects this type of detention has on child and adolescent health outcomes such as: high risk of psychological stress that may lead to anxiety and depression due to separation and forced detention, suicidal ideations, victims of assault by other children in these detention centers, or sexual assaults from other detainees or employees at these facilities.
  • In South America sovereign nations have closed their borders or placed restrictive regulations on Venezuelan migrants seeking food, shelter, and basic medical care for their families amid a massive economic crisis. Not only do these migrants face arduous journeys, but they also face poor health outcomes like malnutrition due to starvation, and the potential for contracting diseases due to poor sanitary conditions, and consuming non-potable water.
  • Migrants are a vulnerable population who can succumb to human trafficking and the modern slave trade along their migration routes. Migrants that are caught up in human trafficking often face abuse (mental and physical), serious injury from due to extreme work conditions, and exposure to communicable diseases from overcrowded and unsanitary living environments.   

Humans take immense risks to seek safety and new opportunities that they did not have in their home country. As an international public health community, whether we work in crisis situations or not, we must make it a priority to treat all humans in a humane manner. Health is a human right, and should be guaranteed for all.