Sunday, 28 April 2013

Help the mother, help the child, secure the future: maternal and child health in India

Photo (c) Children In Need India

Like many people ‘of colour’, I am occasionally subject to a random dousing of imprecise and pejorative cultural clich├ęs by ignorant people with a superiority complex, just like a delicate lotus blossom caught in a balmy, allegorical, toxic monsoon shower.
Woman in publishing, at literary festival: “What do you do?”
Me: “At the moment I’m working with the Gates Foundation and Johns Hopkins University, reporting on international development? No, before you ask, I haven’t met the Gates’s. The next thing I’m doing is on maternal health, I think. It’s really interesting.”
Woman in publishing: “Oh! That’s so interesting because the other day I was thinking to myself, I had trouble with my two pregnancies and if I’d been having my babies in the developing world, I wouldn’t have survived. Do you know [random British Asian woman in publishing PR]? Because you look like her and you remind me of her.”
Me: ???
I have no doubt that I in no way resemble the one other Asian person Publishing Woman has met in her working life. Poor PW, we met for 10 minutes out of nowhere and she couldn’t stop talking about race, refugees, poverty and the pathetic ills of the ‘developing world’ – it’s like she had racial Tourettes. And had I been able to recover from the speechlessness that afflicted me at the crucial moment, despite the fact that I talk for a living, I would have asked her which country exactly in ‘the developing world’ (which bigots usually take to mean everywhere or possibly anywhere from Senegal, across Libya, Somalia, Congo, down to Mozambique, then up through Iraq, Iran, Afghanistan, Uzbekistan, definitely India, Pakistan, Bangladesh, Sri Lanka and then possibly through to rural China perhaps… and maybe Burma, or rural Indonesia…and maybe also acrossways to some countries in South and Latin America, oh and the Caribbean islands maybe too, and gosh even some parts of Greece?) she meant, and then which region in which country.

The whole thing – or rather, her gloating and ignorance – made me think of an article I wrote a long while back, about Children in Need India. I described ‘two Indias’: that of the extremely numerous privileged middle class, who have the finest education, prospects, family support, influence, connections and healthcare; and that of the poorest, who despite the general dynamism, ambition and industry of today’s India still suffer due to lack of access to healthcare, education, influence, rights and justice. So often, it is only the second India that the wider world sees. It pains me, as a British Indian, that the rest of the world is blind to the incredible humour, energy, intelligence, broadness and enlightenment I see everywhere in India. In many ways, as a woman I find Indian culture much more sisterly and infinitely less misogynistic, judgemental, brittle, sleazy, objectifying, ageist-sexist and dollybirdish than British culture – but that’s a subject for another article.

Still, when it comes to society’s least advantaged, there are certain issues which cannot be ignored. India has a population of around 1 billion people and poverty, hunger, illness, gender and class injustice, lack of access, lack of rights, abuse, exploitation and geographical isolation from sources of both power and assistance (such as healthcare) are disproportionately weighted against those with the least. In short, despite India’s great achievements and many distinguished citizens, there are still an awful lot of poor, disempowered, ill and hungry people.

Looking back through Children in Need India’s work since I wrote that first 'two Indias' article, it is clear that solving the most fundamental problems must start from birth. I was intrigued by CINI because it started up with just two clinics for deprived children in Kolkata, where my mother’s family are from, and has since grown into a much larger organisation operating in West Bengal.

They present some sobering statistics, from Unicef studies:
  • Infant mortality is highest in India than anywhere else in the world. According to Unicef’s 2010 figures, the majority of the 6,000 children who die in India every day, the majority are from preventable causes.
  • Almost a half of all children under the age of five in India are clinically malnourished (Unicef study, January 2012)
  • According to Unicef’s 2005 figures women in India are 80 times more likely to die during childbirth than in the UK due to lack of access to basic healthcare and monitoring during pregnancy for poorer women, as well as malnutrition and anaemia, which are linked.
There are further statistics – all, sadly, predictable – relating to rates of child labour, the possible consequence of exploitation and abuse of children who labour, the young age of girls’ marriage in rural areas, relatively low rates of child education (education in India is now free for all but uniforms and books can be expensive) and the knock-on effect in terms of adult literacy and, of course, gender equality.

This month the Wilson Centre in America held an extremely wide-ranging conference on Maternal Health in India: Emerging Priorities. There is a brilliant sum-up and full footage of the conference here. Taking place across New Delhi, Boston and Washington, the speakers argued strongly for the issue of maternal health to be seen in the context of multiple underlying social, health and economic factors, pointing out the importance of various key factors. First, more attention must be paid to women's health after giving birth - focusing on morbidity, not just mortality - and ensuring that all of a woman's health needs, from family planning to sexual health, are met in the same (geographical) place by the same people or organisation. Second, there must be an understanding of he importance of family planning: fewer pregnancies, with longer gaps in between, are better for women's physical and mental health and the health of their babies. And third, the importance of post-partum health care and sustained treatment cannot be underestimated.

Underlying all of this are the effects of gender inequality on women's health: early marriages leading to early and numerous births; violence against women; the underprivileging of female family members when it comes to feeding/serving, leaving women with the worst and least food (leading to malnutrition and anaemia) and the most and hardest labour within the house and beyond it. Class is also a powerful influence on Indian women's access to healthcare: disenfranchisement due to caste or other low class status is serious and widespread.

When it comes to healthcare, the best work is done through direct outreach, local engagement and the creation of long term relationships and structures: in one film, CINI describes visiting people door to door, inviting local people to meetings, the setting up of ‘panchayat’ council meeting where citizens speak up about what they need and are also educated and informed of their rights. In this way, the fundamentals – health, education, nutrition – are slowly strengthened. One intriguing project, which kills two birds with one stone (so to speak… actually it gives life to two birds with one stone…) is the ‘Nutrimix’ nutritional project: this is a pre-mixed nutritional food supplement which benefits Under-5s, which is sold by women to their local communities at a low price, but with a  small profit. It incentivises the women to sell and benefits them financially, while also aiding child health.

Other solutions are more traditional, like drop-in clinics giving advice on prenatal care, nutrition, vaccinations (one doctor talks positively about the success of the polio vaccination project at her clinic – once mothers see how simple it is, they are bringing as many local children as they can), reproductive health and more. Still, the strong theme of gender inequality, sexual exploitation and hypocrisy cuts through all of these issues. The clinic deals with STI’s, among other things, and it is left tactfully open as to where the STIs come from (hint: it’s not the women). Many of the women having babies are under-nourished because, even in a generally poor family, the men and boys will be privileged and the mother will eat last. In the film, one doctor at a baby clinic gestures to a patient and points out that the woman (and by consequence her baby) is under-nourished and in frail health because, due to a lack of contraception and consideration from her husband, she has too many children, who she can’t feed and is visibly too exhausted to look after.

Still, it is these same women who are finding a voice. From the seemingly small act of seeking and receiving healthcare treatment they are empowered to take a stand not only in their local area – one example is of women going door-to-door and educating their neighbours about the importance of environmental health and sanitary local conditions, which help to prevent the spread of germs – but also speaking out against the marrying-off of girls at a young age and insisting on the right for all children, whether they are boys or girls, to be educated. They are also empowered to demand safe and adequate healthcare. As one woman says: “We also want all mothers to be able to give birth in a hospital, without the risks of a home birth.”

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Friday, 5 April 2013

Indonesia is just one example: introducing the International Year of Water Co-Operation

Image (c) UN
World Water Day was just a few weeks ago, on 22nd March, and this time around it’s part of 2013’s special International Year of Water Co-Operation. While I’ll write more about water, health and development in coming months, the poster below gives some impression of just how many individuals, informal groups, charities and organisations have been active in the fight to provide universal, accessible, clean and safe water for all the world’s population on World Water Day. 

Image (c) UN
At the same time, world leaders are meeting throughout the year to seek ways to co-operate and fund initiatives to make these goals a reality for everyone. On World Water Day itself there was a High Level Forum at the Hague and a High-Level Interactive Dialogue (love those crushingly literal antieuphemisms!) at the UN headquarters in New York and other summit meetings are planned in Stockholm, Tajikistan and Norway throughout the year.

To give some idea of the considerations and challenges which arise when looking at water and development I want to take USAID’s work in Indonesia as a case study, based on recently released details of their initiatives there as part of the $33 million, five-year IUWASH (Indonesia Urban Water, Sanitation and Hygiene) Project. In support of the country’s Millennium Development Goal (MDG) regarding improvements in water provision and sanitation, IUWASH reaches out across more than 50 municipalities, helping up to 2 million people in urban areas access safe water and improving sanitation for many others

According to USAID,
  • Around 40% of Indonesia’s urban households have access to clean water
  • Just over 50% have basic sanitation
  • In all, 75% do not have “adequate sanitation”
  • Poorer families are disproportionately affected – so, as in so many places, there is a gap in privilege, resources, access, opportunities and advocacy (that is, the clout to be heard and make social changes) between the richest and poorest. 

The principal barrier to safe, piped water in urban areas in Indonesia is financial: the installation and connection charge of between $150 and $300 might be as much as three months’ an average earner’s salary – USAID cite a typical example of a vegetable seller and mother of two from Jiyu, earning $2-$3 a day which barely covers essentials as it is. For those without access to piped water, water must be collected and carried from the nearest river or reservoir, a task which is extremely arduous, time-consuming and inefficient. One person can only bring as much water as they can carry. This must be shared amongst the family and amongst cooking, bathing and clothes-washing requirements.

A further difficulty is that in the implementation of a piped water network, a number of processes, vested interests and various groups must be aligned. Strategy, goals, budgets, funding, decisions and policy come from the government, with or without the collaboration of other governments, agencies or funds internationally; geographical planning, irrigation, building and the establishment of utilities, sanitation and facilities will all be handled by private businesses and so on.

Photo (c) USAID Indonesia project

With access achieved, the next issue to tackle is sanitation. USAID estimates that in Indonesia

  • only about 2% of urban households are connected to sewerage systems
  • up to 18% of urban dwellers must defecate openly, without facilities for the removal of waste
Here, the solution is consciousness-raising about sanitation issues and good practice, people’s unity in improving conditions for everyone and the importance of local leadership in effecting change among multiple households, encouraging families to build improved sanitation facilities like latrines, practice good hygiene (which can be as simple, but effective, as hand-washing, medicated cleaning products and the separate of areas for different tasks). The swift and obvious success of these often-simple measures – such as a steep decrease in rates of diarrhoea and an increase in general health – often inspires communities to go further in terms of grassroots local development, towards recycling and composting.

This is achieved through all parties pulling their weight. IUWASH and similar initiatives must bring together all these different parties to ensure long-term planning and delivery and create a new, different, sustainable future.

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

Tuesday, 2 April 2013

Indian court rules that you can’t hold the developing world to ransom when it comes to medicines that would save millions of lives

I just saw this on the BBC and had to cover it because it highlights some of the many issues surrounding patients’ access to effective long term medical care in the developing world, illustrating how the humanitarian issue of global health can become subject to issues of profit, politicking and power.

The Swiss pharmaceutical company Novartis has had its patent application for a newer version of an already-available, expensive and effective leukaemia drug called Glivec rejected by the Indian Supreme Court. Novartis had been trying for six years to obtain the patent, but the court ruled that patent status requires and recognises clear innovation resulting in proven increased efficacy  rather than minimal adjustments to an existing product.

This ruling sends a strong message about the potential for patients in developing countries to access affordable medicine. First, it prevents large, international pharmaceutical companies from protecting much-needed medicines through patents which result in product exclusivity, lack of competition and the levying of a high sale price by the drug’s ‘owners’. Second, the court’s ruling indicates support for the manufacture of non-brand-name copies of the drug by generic companies in India (a major medical manufacturer serving many developing world countries). These can be sold at a much lower price to meet widescale medical need. For example, Glivec costs nearly thirty times as much, per patient, per year, as the generic version of the same drug manufactured in India.

As Avert, the international anti AIDS/HIV charity, explains:
A generic drug is an identical copy (bioequivalent) of a brand name (or proprietary) drug. Generics are exactly the same as their branded counterparts in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. The notable difference between the two is the price.
 While this week’s ruling concerns a leukaemia drug, its principle can be extended to treatments for HIV and AIDS medicines. India’s manufacture and export of affordable HIV medicines (and other generic drugs) has benefited millions of sufferers in the developing world, most notably to treat AIDS epidemics in Africa.

The competition amongst generic manufacturers, consciousness-raising among global health advocates and close collaboration with pharmaceutical companies have resulted in falling prices, which have put medicines – especially specific treatments for HIV and AIDS – into the reach of many millions more people in poorer regions.

At the heart of the issue in this particular ruling is patients’ right to affordable treatment. The right to be healed, where healing is available and has been proven effective, should not be denied to a sufferer because they are poor.

What is chilling, however, is Novartis’s response. In a TV interview after the ruling, the company’s vice chairman (and MD in India), Ranjit Shahani, hinted that the decision would have a negative impact on Novartis’s plans for investing in India, doing further research and development or introducing new drugs to India.

This is, effectively, a blackmail threat*: allow us to keep our vital drugs exclusive and expensive or we will freeze you out of the game completely, new research will grind to a halt, new medicine access (no matter how inaccessible, discriminatory and unaffordable) will cease altogether and millions will die.

The fact that large companies are willing to try and play tactical threat-games with people’s lives is disturbing and amoral. If international pharmaceutical corporations cared about people suffering major illnesses it would back the democratisation, universalisation and affordability of treatments and demonstrate through its actions that it values curing people more than making a profit, because human beings are more important than money.

Further reading:
-        Sarah Boseley has covered this particular case very clearly and thoroughly here in The Guardian
-        There’s a clear BBC new report with a very interesting analysis by Indian journalist Shilpa Kannan on the Glivec case.
-        The international AIDS/HIV charity Avert has comprehensively set out the basics when it comes to costing, manufacturing and supplying treatment and medication for sufferers.
-        Avert has also produced an interesting report on the history of, challenges to and ways forward for universal access to HIV/AIDS treatment, if you click here.
-        There are extremely thorough reports on the provision of AIDS/HIV medicines in the developing world, produced by the Interagency Coalition on AIDS and Development (ICAD). Click here and then click on the Our Work and Publications Tab.

…And, to add my feminist twist, there’s also a very pertinent feature on the link between HIV/AIDS and gender inequality:
Many of the social and economic barriers that stand in the way of effective HIV prevention, treatment, support and care for people living with HIV are the same barriers that impede access to comprehensive sexual and reproductive health programs and services. For instance, the circumstances that can lead to unintended pregnancies can also lead to infection with HIV and other STIs. Sex is the common denominator. In societies where cultural and gender norms tightly restrict the sexual and reproductive lives and choices of women and men, the risk for both unintended pregnancy and HIV infection is greatest.
Jennifer Kitts and Nicci Stein, ICAD

Bidisha is a 2013 Fellow for the International Reporting Project. She is reporting on issues of global health and development. 

* and one which is common in the rhetoric of many large companies – I don’t want to single out Novartis for blame in behaving like all its peers