World AIDS Day & the need for SSPs

by Kendall Penndorf, posted in APHA IH Section, HIV/AIDS

December 1st, 2016 marked World AIDS Day.  This year’s theme is “Leadership.  Commitment. Impact.”  The White House National HIV/AIDS Strategy for the United States praises the collective efforts of the healthcare workforce, including “increased access to new, sterile syringes and other injection equipment to minimize infections from injection drug use.”

Syringe services programs (SSPs) have proved beneficial to countries across the globe.  In Hong Kong SAR, pharmacies can provide new syringes without a prescription.  Surveys by the health department find that only 2% of HIV infections are attributable to persons who inject drugs (PWIDs) in this country.  In Berlin, Germany, 77% of PWIDs use syringe vending machines at least 4 times per week.  Elsewhere in Germany, syringe SSPs in jail dramatically reduce rate of new infections.

The evidence is clear: Syringe exchange programs work.  Not only do they decrease HIV transmission among PWIDs, but they don’t recruit new drug users and they are cost-effective compared to treating individuals with HIV.  So what’s the hold up?  We need only look at the United States to see that legislation for SSPs is far from universal.

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There are currently, 228 SSPs in 35 states, the District of Colombia, Puerto Rico, and the Indian Nations.  In states without SSPs, the impact to PWIDs is devastating:

In jurisdictions in the United States, where drug paraphernalia laws were strictly enforced, higher prevalence of HIV infection was observed despite lower risk-taking behavior.  Legal barriers in Maryland and Texas in the United States resulted in a high prevalence of HIV with   up to 25% of PWIDs infected in Baltimore, Maryland and 35% of PWIDs infected in Houston, Texas.  These findings overall suggest that injecting paraphernalia legislation that restricts needle and syringe availability inadvertently increases HIV infection.  There is no convincing evidence that this legislation reduced HIV prevalence.

Whereas Maryland now has one SSPs, Texas is still one of 15 states that do not offer this service.  This is especially concerning due to the prevalence of HIV on the US-Mexico border. Made possible by a combination of illegal and legal sex work, PWIDs, and the highly transient nature of the population, HIV is rampant and largely unchecked in Mexico border towns adjacent to US cities.

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While syringe exchange programs are key, more needs to be done to educate the citizens of both countries:

And with Mexico’s border cities serving as funnels for workers and goods traversing the two countries, Tijuana’s AIDS crisis poses a direct threat to the United States.

“I call HIV the uninvited hitchhiker,” said Steffanie Strathdee, a leading AIDS researcher at the University of California’s Division of International Health and Cross-Cultural Medicine.

A survey by university researchers found that 64 percent of 116 HIV-positive Tijuana residents crossed into the United States at least once a month. Nearly half of men having sex with men in Tijuana and 75 percent of those in San Diego reported having partners across the border. And of 1,000 prostitutes interviewed in Tijuana, 69 percent had U.S. clients who crossed the border for their services.

The federal ban on syringe exchange programs was lifted in the first few weeks of 2016, largely in response to a nationwide heroin and HIV epidemic in America’s heartland.  Federal monies cannot be allocated to purchase needles, but cover all other expenses including staff, vehicles, and gas.  State and local funding could be used to purchase needles.  Still, adoption of programming has been slow.

Globally, only 90 needles are available per PWID annually.  This is less than half the recommended amount of 200, and many countries provide far fewer.

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With a dubious history of HIV prevention and intervention, it is no wonder Russia’s HIV epidemic is increasing 10-15% each year.  Recent data show that 1 in 50 people in Russia’s 4th-largest city are HIV-infected.  When outside funding for SSPs was withdrawn in 2010 – as Russia was then classified as a high-income country – SSPs dwindled from 80 to 10.  Intravenous drug use accounts for 58% of HIV infections.

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Under Putin’s conservative regime, HIV infections have nearly doubled since 2010 – 500,000 to 930,000 registered carriers – and are projected to reach 3 million (2 million registered carriers) within the next 5 years.  Despite annual spending of $418 million (US) rates are increasing as the lion’s share is spent on antiretroviral therapy, not prevention.

President-elect Trump has been surprisingly vocal in praising Putin, and unsurprisingly obtuse about how he plans to address HIV domestically and abroad.  When asked whether he would support the President’s Emergency Fund for AIDS Relief, Trump was not un-supportive:

Well, I like committing to all of those things. Those are great things. Alzheimer’s, AIDS, so many different — you now, we are close on some of them. On some of them, honestly, with all of the work that has been done — which hasn’t been enough, we are not very close. But the answer is yes. I believe so strongly in that. And we are going to lead the way.

In perhaps the weirdest twist yet, Vice President-elect Mike Pence could prove to be an ally for continued funding of SSPs in the US.  In 2015, an upsurge in HIV infections in Indiana led then-Governor Pence to advocate for syringe exchange programs after a career of staunchly opposing such legislation.

And what of those border states?  Perhaps Trump’s fabled wall might come in handy.

Video @WHO: Intimate Partner Violence

by Kendall Penndorf, posted in APHA IH Section

Home should be a place of safety and sanctuary, but for a third of women, this is not the case.  Around the world, 800 million women are subject to physical and sexual abuse at the hands of their husbands and partners.  Per the World Health Organization, intimate partner violence (IPV), also includes emotional abuse, such as threatening to take children away, and controlling behaviors, including isolation and restriction of financial resources, employment, education, and medical care.

IPV causes injury and death, mental health and substance abuse issues, and harm to children who are born to women abused by their intimate partner.  That being said, intimate partner violence isn’t a women’s issue.  IPV is a social concern that runs rampant and largely unchecked in any society that supports – implicitly or explicitly – sexual assault and rape.  Counter to the woman-as-victim trope, violence can occur in any intimate relationship, including between same-sex couples.

What can we do to help millions of men, women, and children in violent homes?  Dismantle those structures which facilitate power imbalance between partners as well as systems that support sexual violence.

Rape culture is a term that is bandied about in regard to leniency and light sentencing of perpetrators, especially on college campuses, in the military, or if the perpetrator is an athlete.  Instead, victims of rape bear the brunt of the burden, such as in the case of a 14-year-old student raped repeatedly by her 49-year-old teacher.  The rapist was sentenced to one month in jail.  The victim took her own life.  A judge declared that the victim was equally in control of the situation because she “seemed older” than her chronological age.

Rape culture doesn’t exist just in our most esteemed institutions, but in the laws that govern our behavior.  A 2010 article published in The Georgetown Law Journal speaks to one of these laws, which allows rapists to seek visitation and custody of children conceived through rape.  Contrary to former State Representative Todd Aiken’s assertions, women can indeed get pregnant as a result of rape as the female body has no mechanism to “shut the whole thing down.”

Once again, we confront another myth of rape culture: that children conceived through rape are unloved and women who choose to keep these children are not true victims.  Statistics show that 80% of rape victims know their attacker, and without laws to revoke paternal custody, some will be forced to continue association with their rapist for at least the next 18 years.

What other institutions contribute to domestic violence?  Child marriage itself is a form of violence perpetrated on some 37,000 girls each day.  Girls who are married before the age of 18 are twice as likely to be beaten and three time more likely to be raped by their spouse.  Abuse is so endemic to this institution that a third of girls married before age 18 believe that, under some circumstances, a man has the right to beat his wife.

For society as a whole, rates of intimate partner violence are intricately associated with the state of society as a whole:

On issues of national health, economic growth, corruption, and social welfare, the best predictors are also those that reflect the situation of women. What happens to women affects the security, stability, prosperity, bellicosity, corruption, health, regime type, and (yes) the power of the state. The days when one could claim that the situation of women had nothing to do with matters of national or international security are, frankly, over.

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As you can see, there is a lot of work to be done.

Further Reading:

Sexual Violence is a tool of war, but we have the weapons to end that.  The Guardian

Guatemala sexual slavery verdict shows women’s bodies are not battlefields.  The Guardian

Ten Things to End Rape Culture.  The Nation

Attacks on Health Care Workers in Syria and the Weakening of the International Community

by Jean Armas, posted in APHA IH Section, Conflict and Health, Human Rights

Before the conflict began, Syria’s health care system was one of the most advanced in the Middle East with chronic diseases ranking as the most common health concern, vaccination coverage rates at 95%, and their pharmaceutical industry producing over 90% of the country’s medicines. Five years later, the conflict has nearly decimated the health care system and today nearly half of the country’s public hospitals and primary health care systems are closed or only partly functioning, almost two-thirds of health care workers have left the country, domestic production of medicines is down by two-thirds, and the vaccination coverage rate has dropped by half. Correspondingly, life expectancy has dropped by nearly 14 years.

Since the Syrian conflict began in 2011, Physicians for Human Rights has documented 382 attacks on 269 different medical facilities and 757 deaths of medical workers. The patterns of attacks clearly demonstrate that health care facilities and workers are being deliberately targeted. When health care workers are attacked, innocent civilians are deprived of the life-saving interventions needed for both routine and emergency care. In Aleppo alone, a health care facility is targeted every 17 hours and a health care worker every 60 hours. These alarming statistics make Aleppo one of the most dangerous places in the world to be a health care worker. APHA Executive Director Dr. Georges Benjamin noted the dire state of the Syrian health care system in a letter to the UN Security Council last December, but the situation has only worsened since then.

According to a recent report in September of this year, there were only 30 doctors serving the estimated 250,000 residents trapped in rebel-held eastern Aleppo. There are currently no more hospitals functioning at full capacity in eastern Aleppo. With the huge upswing of Syrian military activity these past few days, it is likely there are far less doctors or hospitals left. To make matters worse, humanitarian aid to eastern Aleppo has been severely restricted. Since humanitarian operations started over two years ago, the UN has conducted 420 convoys to deliver medical supplies and food to eastern Aleppo however as of late, they have not been able to make their deliveries. Health care cannot exist without health care workers, supplies, and facilities.

International humanitarian law and medical neutrality have been established to protect health care facilities and workers to ensure that they can continue to provide care during armed conflict and not be prosecuted for providing services to protesters or opposition fighters. But when health care facilities and workers are purposefully targeted and humanitarian aid is withheld, there is a clear violation of international humanitarian law that should be punished accordingly as a war crime. Though the violations in Syria are some of the most flagrant, these deliberate attacks on health care facilities and workers, used as a weapon of war, occur in many other parts of the world as well. In Yemen, over 600 health facilities have been targeted since fighting began in 2014. Médecins Sans Frontières (Doctors Without Borders) has gone so far as to call attacks on health care facilities and workers during times of war as the new normal. Additionally, health workers in Bahrain were arrested, imprisoned, tortured, and charged with crimes for caring for protesters and documenting police brutality in response to the Arab Spring uprising in 2011.

Although news outlets and humanitarian organizations worldwide have brought a lot of attention to these tragedies, bringing awareness to these atrocities is not enough to stop it. It is the responsibility of the international community to help put an end to such blatant threats to human rights. The UN’s Responsibility to Protect gives permission to the international community to intervene and protect populations when a state fails to prevent and halt genocide and mass atrocities. However, the operationalization of this doctrine has proven to be disappointing. Although most actors in the international community agree that something should be done, they have been unable to agree on exactly what must be done. No-fly zones have been suggested and temporary ceasefires have been adopted to ensure delivery of humanitarian aid but both are merely stopgap measures. These are not enough to put a stop to such unnecessary human suffering and should not be the final solution.  

As the war approaches its sixth year, the future of Aleppo looking bleak, and current estimates of the death toll in Syria surpassing 470,000, the need for for the international community to help put a permanent end to the war could not be more dire. However, given the international community’s long track record of ineffectual measures, it is unclear how they will proceed. One thing is for certain, it’s about time for the international community to ask themselves whether the decisions (or indecisions) they’ve made with Syria and other conflicts have been consistent with the principles of the Responsibility to Protect doctrine. Human lives are at stake and from a human rights standpoint, this should take precedence over any personal or state interests.

2016 Public Health Gift Guide

by Kendall Penndorf, posted in APHA IH Section

On this most hallowed online shopping day, Cyber Monday, as we traverse a plethora of retailers – from Amazon to Zappos – take a moment to check out these charities that are addressing much-needed pubic health issues:

1.This bar saves lives. Otherwise known as Plumpy’Nut, this shelf-stable, nutrient-rich paste made from peanuts, milk powder, sugar, vegetable oils, vitamins, and minerals saves the lives of severely malnourished children worldwide.  Hailed as the most important public health innovation since penicillin, Plumpy’Nut’s little brother, Nutributter, is designed for children under two to prevent stunting caused by malnutrition which can save children from lifelong health issues.

Partnering with Save the Children and the Foundation for International Medical Relief of Children, Plumpy’Nut produces amazing results for very little money.  It costs $50 for a two-month supply.

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How can you help? It’s easy: Buy a bar, feed a child.  Every purchase of the Non-GMO, gluten free, fair trade, bee friendly bars gets Plumpy’Nut to the children who need it most.  Click here for a 60 Minutes piece about Plumpy’Nut.

2.  Apopo. As a rat owner, Apopo is a cause near and dear to my heart, and one I’ve written about before on this blog.  Apopo trains Gambian pouched rats to save lives through mine and tuberculosis detection.  From humble beginnings in 1998, Apopo has exploded (pun intended) into a force that has destroyed over 100,000 landmines, cleared 20 million square meters of land, and freed nearly a million people from the threat of explosives.

Apopo added tuberculosis detection to its ratty repertoire in the mid-2000s.  Rats can sniff out TB in a fraction of the time it takes to run a diagnostic test, and with great accuracy.  This means that over 10,000 additional TB cases have been detected with 60,000 TB infections halted.

Training rats takes time and money, but the people of Apopo have made your Holiday shopping that much easier.  Donations between $10-20 will buy a basket of bananas (a favorite treat of HeroRats), safely detonate one landmine, or provide a health checkup for one rat.  If you have a little more to give, consider $32.00 to clear 30 square meters of a minefield or $56.00 to screen 200 TB samples.

Want to follow the journey of a HeroRat?  Consider adoption!  For $7.00 a month, you can adopt a rat.  Your donation comes with a welcome pack, adoption certificate, and monthly updates about your rat’s progression and life-saving successes.

3. Days for Girls. Nothing quite says Happy Holidays like a donation of menstrual care products, but the reality is that girls worldwide miss school and face social isolation because of their periods.  Without modern menstrual products, girls are forced to use whatever they can find, including leaves, rags, mattress stuffing, feathers, and cow dung to name a few.

Days for Girls makes it easy to get involved.  Can you sew?  Consider making Days for Girls kits, which included washable, reusable pads, soap, washcloth, two pairs of underwear, and visual instructions on use of all items.  You can also join an international team or fundraisers or donate directly to this great cause.

Dignity for girls during their period is the first step toward making 2017 the Year of the Girl!

4. Against Malaria Foundation. In 2015, there were 214 million cases of malaria worldwide.  While deaths caused by malaria have decreased nearly by half between 2000 and 2015, there are still roughly half a million deaths each year.

For just $2.50, you can send one long-lasting insecticide treated net (LLIN) which lasts for 3-4 years and protects up to two people from mosquitos that are most active between 10 pm and 2 am.  For every 50 to 250 nets that is implemented, the life of one child is saved.  So far, nearly half a million people have donated $92 million to distribute over 30 million nets.  One-hundred percent of your donation goes toward purchase and distribution of LLIN.

5. The Natural Resources Defense Council. If saving the planet is your thing or you’ve read the startling report that the world’s top soil could be gone in 60 years, the Natural Resources Defense Council (NRDC) is for you.

Focused on all aspects of the environment, from climate change, to food, to the wild, NRDC is working hard to safeguard our planet in a way that is meaningful to you.  You can donate to save elephants, protect the ocean, or give the gift of clean water.

So, there you have it!  A very short list of some worthwhile causes that could use some help today and always.  Know of a great charity that is addressing a public health issue?  Leave it in the comments below.

Disclaimer: The International Health Section is not affiliated with nor does it endorse any of these organizations.  All opinions are the author’s own.

Global News Round Up

by abbhirami, posted in APHA IH Section, News

Politics & Policies

Regulations to fight climate change likely will be casualties of the incoming Trump administration, but environmental experts taking stock of the changing American political landscape said that work in the field will continue elsewhere and that a broad-based rollback of U.S. environmental protection will prove easier said than done.

2015 marks the fourth year that the Kaiser Family Foundation has been analyzing donor government funding for family planning, tracking progress against commitments made at the 2012 London Summit on Family Planning.

Last week, the world was shocked by the news that Donald Trump would become the next United States President. In this post, Emory University’s James Michiel takes a first look at how this surprising result might influence global health in the coming years.

Programs, Grants & Awards

UN World Toilet Day highlights the urgent need to address a global sanitation crisis by providing toilets and sewage management systems and to aggressively implement programs of WASH (Water, Sanitation, and Hygiene).

Research

Domestic violence during pregnancy needs to be addressed at different levels in Nepal, where women are often dependent on others for access to health care.

Global performance of epidemiologic surveillance of Zika virus.

Dengue fever, caused by the dengue virus (DENV), is now the most common arbovirus transmitted disease globally. One novel approach to control DENV is to use the endosymbiosis bacterium, Wolbachia pipientis, to limit DENV replication inside the primary mosquito vector, Aedes aegypti.

Diseases & Disasters

Scientists say they may have found a way to protect babies in the womb from the harmful effects of Zika.

In a Sierra Leone village considered an Ebola “hotspot” during the epidemic, researchers discovered 1 year later more than a dozen people with minor symptoms of infection that had gone undetected.

Since the beginning of 2016, the humanitarian partners working in cholera response identified a risky scenario created by the increase in the number of suspected cholera cases and the decrease of funding to fight the disease.

The World Health Organization (WHO) announced Friday that it no longer considers the Zika epidemic a public health emergency of international concern.

Technology

Funding for phase one of pilot deployments of the world’s first malaria vaccine in sub-Saharan Africa has been secured and immunization campaigns will begin in 2018, the World Health Organization (WHO) said on Thursday.

Environmental Health

The Flint water crisis hasn’t gone away. Thousands of the city’s residents are still at risk from the water supply. The city has switched back to Detroit water, but experts say the distribution system will never be the same.

The EU’s environment watchdog has said air pollution is “the single largest environmental health hazard in Europe.” Around 467,000 premature deaths in 41 European countries were linked to air pollution in 2013.

Back in late September, Polk County officials spilled five gallons of fuel while refueling a generator at the Babson Park Water Treatment Plant. How do we know this? We know this because Gov. Rick Scott wants us to know this.

The Trudeau government has taken important steps to assert Canadian leadership on environmental issues after years of neglect under the Harper government.  Now it plans to phase out almost all use of coal to generate electricity by 2030, a move that will cut greenhouse gas emissions while producing significant health benefits from cleaner air.

Equity & Disparities

Unsafe drinking water is a bigger problem for minority communities in the US than for white communities, suggests a new study from the University of North Carolina, Chapel Hill.

GSK has today been ranked first in the Access to Medicine Index for the fifth time, taking a leadership position in research & development; pricing, manufacturing and distribution; and product donations.

Disparities in health and health care remain a persistent challenge in the United States. Disparities not only result in inequities but also limit continued improvement in quality of care and population health and result in unnecessary health care costs.

Maternal, Neonatal & Children’s Health

Community health workers (CHWs) have the potential to reduce child mortality by improving access to care, especially in remote areas. Uganda has one of the highest child mortality rates globally. Moreover, rural areas bear the highest proportion of this burden. The optimal performance of CHWs is critical.

Sebastian Vollmer and colleagues (April, 2014) conclude that “the contribution of economic growth to the reduction in early childhood undernutrition in developing countries is very small, if it exists at all.”

Diarrheal disease is the second-leading cause of death for children under the age of five.  And it disproportionately affects kids in the developing world, where it’s tougher to access safe water and medical care.

The global news round up was prepared by SS.