Month: January 2014

By Esnatt Gondwe

My brother in-law recently shared this quote with me:

“Hope is not the conviction that something will end well, but that it makes sense, no matter how it ends.”– Vaclav Havel 

When I read this quote, it made me think about my fellowship year.  Before starting the fellowship I didn’t know what to expect. I entered the fellowship year with hope, faith, and excitement, but each of these emotions has been challenged over the course of these first six months. My hope was challenged by the question of whether the health care system in Malawi will ever evolve; my faith was challenged when I was exposed to darker sides of people and the complexities of working with them, and my excitement was challenged by high ranking individuals who found it hard to accommodate innovation and creativity. Throughout the first six months I had hope that all the challenges we faced would be resolved, and they were. But hope should not only end at the belief that challenges will be resolved, it should transcend to the understanding that even if the resolution does not happen in the way we had hoped, it is still the best possible outcome.

I like to control situations. It gives me a sense of security. Every day I learn that control stops you from growing in hope, because it forces you to put conditions around how a situation should evolve, whereas hope requires you to be more flexible.  There are certain things I can change today, and there are certain things that will have to be taken on by someone else. Control pushes me to want to do it all, but hope provides me with the knowledge that I can’t do everything, and that someday resolutions will come even if I am not directly involved.

We were recently coordinating a fundraising drive for Bwalila Hospital’s Maternity Ward- a very busy, underserved, community hospital in Malawi. We were able to raise money for some items, but while we were placing an order for mattresses, it hit me that there would not be enough matresses for all the women in the maternity ward. This realization filled me with a great sense of sadness and  failure.

I forgot the victory of being able to get some money to buy items for the hospital, and focused on the fact that it didn’t cover all the needs.  I have now learnt that it is necessary to look at what needs to be done, but it is essential to accompany that with looking at what has already been achieved.

We are currently in the processes of writing a proposal for a partner organization that has shown interest to provide the hospital with a grant to cover the remaining needs after the fundraising drive. This may or may not work out, but I have realized that I do not have control over the outcome. I can assist and play a key role, but I cannot guarantee the end result. What I can guarantee however, is that in all the work I do this year, I will give my all, and that will be enough.

We can all collectively strive to carry hope for the future- hope that everything will work out, and hope that however it works out will make sense and will be for the best!

A man far wiser and braver than I once said: “there will be times when we will be powerless to prevent injustice but let never be a time when we fail to protest.”

The reason I am busy doing something every day of my life is because it keeps me in balance. In everything we have talked about during the GHC quarter workshops beginning from the orientation at Yale training, quarter one workshop, mid-year retreat (and likely at Q3 and the close out retreat) there has been some kind of balance. It’s just nature. In nature there is balance and in that balance there is justice. This is in addition to what my upbringing holds. These are virtues I have believed all my life so far and have been amplified by this community. My mother and the environment taught me most of it as she always refused to be broken in the hardest places. She died 5 years ago; she never even had any better health care system apart from the poorly supplied public hospitals and clinics. I remember her being given a 6 months appointment at University Teaching Hospital (UTH).

She underwent a crucial moment and I knew she was never going to make it. One minute she was talking to me and the next second she was gone. And then she died. The last thing she said to me while dying on my lap at home, not at a hospital, was “take care of each other son”. But maybe I need to start thinking about how to forgive the government, governing system, UTH and the doctor(s) for failing the health system in Zambia where people die anyhow for lack of proper medical care. The question is how many people out there die every day because there is no proper justice, because they can’t afford proper medical care. Where is the justice system?

Four years later I lost my dad. The day I found out dad was dying was like any other day. I was sitting in my office working when the doctor called. My first reaction was panic as I was told he had cancer of almost everything. I reached the cancer research building to try and help them find a cure for what was going to kill my dad in less than two months. But I realized right then that there was no use. It was too late. And so I just stood outside the door and got angry. I hated God with a passion for doing this to me. Everything that was dear to me came to an end that day. I lost my friends who I pushed away, I blamed my brothers and sisters, and I went completely broken all within minutes. Just as Pastor Nemoellor came out of the Nazi death camp to say,

“They came after the Jews, and I was not a Jew, so, I did not protest. They came after the trade unionists, and I was not a trade unionist, so, I did not protest. Then they came after the Roman Catholics, and I was not a Roman Catholic, so, I did not protest. Then they came after me, and there was no one left to protest.”

As stated in the opening statement, we have a right, even a duty, to protest against unjust laws and systems which support the status quo that violate the freedoms of the voiceless in our societies, our mothers, fathers, grandparents and even the posterity to come. The first lady has been championing funding for cancer research but I hold nothing against anyone anymore because I don’t want to go to my grave holding bitterness in my heart towards anyone. Today I have set aside prejudice and politics to make room for compassion and sound policy.

I have many stories but this one fits the scenario. When Golden Wilson’s daughter was wounded by a bomber – his daughter’s dying words were “I love you so much dad”. At the hospital, he chose something unexpected; he chose to publicly forgive the bombers for killing his only daughter. And when he forgave them, others who had lost loved ones took a step back and it changed the course of relations for everyone. The bitterness ended and the war almost came to a close.

We still have war, famine, hunger, ailments because very few are willing to stand up because very few have learned to love and feel empathy, to empower others to stand up for their constitutional rights in the midst of intimidation; we have stood looking while our friends have suffered victimization, humiliation, and loss of employment all because they have protested for the rights of “us”. All of us are the world’s problems and until we look into the mirror and see ourselves as the problems we are never going to get anywhere. And so it is easy to develop anger, frustration, and hate for those who either hurt us or hurt our loved ones, but it’s much harder and much more significant to take a stand and start being an answer to the world’s problems. Isn’t this what my mother and father would have wanted to see me do?

In December 2013, the Zambian government dismissed over 100 nurses at the biggest hospital in the country (http://www.lusakatimes.com/2013/12/03/100-nurses-uth-fired/) for protesting against what they purported as poor working conditions. We are told many patients who entirely relied on the poor hospital and clinic conditions died; women gave birth on the floors of the clinics and hospitals, and men and women who were on oxygen supported machines suffocated to death. Whether the nurses were right to demand an improvement in their conditions of service in this manner that resulted in the death of so many patients is for you to judge, and whether the government too was right to punish this huge number of nurses considering Zambia has an abnormal patient nurse ratio, is for you again to judge.

I have no problem with anyone finding an appropriate definition of who Ladislas is, but the question I have for you is who are you? What will you stand for? Is there any meaning you have found to life? What are you willing to still live for today? If you define me as a frustrated and disgruntled young man who has lost his mind for civil and social justice; it is fine. I will live with that tag. You get to choose your choices. If you will try to stop me as I pursue this path, I will surely disappoint you. But if you join hands with me, I will welcome you, and together we shall sound the loudest trumpet that will break the loudest silence of civil and social injustice, for we are all equal but simply different. As the saying goes, “If you want to go fast, walk alone, if you want to go far, walk together; also nothing extraordinary is achieved through ordinary means”. Surely with this global movement for social justice, I am not alone and together, we will reach far.

A group of young professionals working in the international development industry sat down to discuss questions that have been debated for years by academics and practitioners such as Jeffrey Sachs, Dambisa Moyo, and Bill Easterly. Have international development organizations been successful? Does foreign aid work? The young professionals launched into a lively debate, with some defending aid as a worthwhile investment that has improved the lives of millions of people living in poor countries, and others condemning it for causing dependence and breeding corruption.

With traditional donor countries in North America and Western Europe facing budget constraints, the debate over the effectiveness of aid is likely to intensify. But before this issue is debated, we need to first establish what the purpose of aid is, how the impact of aid and international development organizations should be evaluated, and what types and amounts of assistance are most beneficial in each circumstance.

Firstly, aid and other development assistance can serve two general purposes. One of these purposes is not to turn poor countries into rich countries. The process of development is incredibly complex, and often involves the complete political, economic, and social (and sometimes cultural) transformation of a nation and its people.  There is still much debate on the causes of development, but in my opinion, domestic governments, businesses, and social groups, not foreign donors, are the driving forces of development.

What aid can do is to a) contribute to the process of development through small, yet important contributions at key moments to feed a virtuous circle, or b) help to relieve the suffering caused by extreme poverty. Contributions that spark a virtuous circle may include the transfer of technology or training that improves agricultural productivity, lays the foundation for start-up businesses, or drastically improves the ability of government ministries to do their jobs. The additional income from agriculture or a new industry, or better public management could lead to better policy, increased economic growth, and eventually development and poverty reduction. Interventions that relieve the suffering of the poor include the elimination of infectious diseases, programs to improve and expand education, and micro-lending to help poor people start small businesses. In one example of this type of aid, I am working on a program to reduce the burden of Elephantiasis and other tropical diseases in Latin America as part of my GHC fellowship at the Inter-American Development Bank.

Now that we have defined the purpose of foreign aid, we need to change the way aid is evaluated. The effectiveness of assistance programs should be measured on an individual basis through randomized trials and other evaluation techniques. Policy-makers should ask if each program has achieved their objective: Has it created a virtuous circle of development? Has it relieved the suffering of the extreme poor? Foreign aid should not be evaluated based on how many countries “graduate” from poor to developed. Aid alone cannot achieve such an ambitious goal, and that is not its purpose.

Finally, understanding the purpose of aid should make it easier to determine what type of foreign assistance should be deployed in which context. I argue that aid to spur a virtuous circle should be reserved for countries that are poor yet relatively stable. The virtuous circle of development requires a peaceful and somewhat orderly environment that would allow local businesses and the government to take advantage of foreign assistance. Very poor, conflict-ridden countries and middle-income countries should only receive aid meant to relieve the suffering of the extreme poor. Conflict-prone, wildly unorganized countries are unlikely to be able to benefit from transfer of technology or capacity building. Middle-income countries already have strong and growing economies and capable civil servants, and do not need transfers of technology and capacity building. Aid can still be used, however, to improve the lives of poor and marginalized populations that are not benefiting from economic growth.

Hopefully the next round of debates on the “success of international aid” will start with a discussion on the purpose, types, and limitations of aid.

Nick Kristof really hit the nail on the head in his Sunday column in the New York Times “First Up, Mental Illness. Next Topic Is Up to You,” where he called out mental illness as one of the major issues systematically neglected to be given the seriousness and attention it deserves.

Mental illness is still the black sheep of the health world, both domestically and internationally. Like Kristof mentioned, the only time mental health comes up in American public discourse is in reaction to analyzing a human atrocity, usually a mass shooting or serial killer, only further stigmatizing it as a disease “crazy” people suffer from.

It will always be unclear to me as to why we give so much attention to diagnosing and treating physical ailments and forget that the brain is a physical part of the human body, and needs to be taken seriously and treated accordingly.

And just as it is neglected in domestic conversations on health, it is also a last priority in international health work. At the risk of sounding crass, what is the point of pouring all these resources into keeping people alive without also making sure they can go on to live full lives? This is particularly true when treating people living with and coping with life-long diseases like HIV.

This struggle was a theme I noticed over and over again while working with a group of youth living with HIV in Malawi. Yes, it was great that they were able to access antiretroviral treatment, certainly a huge improvement from only a few years ago when even that wasn’t widely available, but that is still not good enough. I explored some of the issues they face in my blog post from 2012, Psychological effects of being born with HIV for emerging adolescents, where it was clear that so many of the adolescents I worked with were suffering from depression and anxiety.

There are few organizations or institutions who measure the number of people suffering from mental illness in developing countries and suicide goes mostly undocumented. It is as though we think that depression and other mental illnesses are diseases only suffered by the privileged, who pay $250 a therapy session. But as far as I’m concerned, if we are going to care for people, we need to care for the whole package, not just pick and choose. The human mind is just as vulnerable as the human body, and both are equally as important to provide care for.

In response to the deficit of mental health providers in Malawi, I helped found an organization called Teen Support Line that focuses on providing psychosocial support for adolescents living with HIV. While we are focusing on a specific demographic, what we’ve found is indicative of what all people need to live mentally healthy lives – someone to talk to; someone who will listen; someone to help them process difficult situations; someone to stand with them; and sometimes medical treatments to target chemical imbalances in the brain. The human mind is just as vulnerable as the human body, and both are equally as important to provide care for, and should be integrated into all treatment plans, no matter where in the world you live.

Normally when people talk about global health and, more specifically, environmental health, they tend to focus on the big, flashy threats – floods, droughts, and toxic waste pollution, to name a few. But sometimes the most innocent and hidden/silent of activities can cause the greatest harm.

For the greater part of my life, especially my life in Uganda, I have been touched by how health related effects caused by the traditional (crude) cooking technologies used among the rural folks are taking away our innocent people. In fact, Uganda derives over 90% of its energy needs from biomass – mainly firewood and charcoal. An estimated forest surface of 115 football fields is used for cooking every day – either in the form of firewood or charcoal. Biomass resources are constantly being reduced because people are not replenishing the cut down trees. This will also support increased environment degradation, accelerating global warming, the rate of desertification and subsequently their related health effects. On a global perspective over 40% of the world’s population still burns various forms of biomass to cook – coal, wood, charcoal, and more. The smoke inhalation caused by burning these fuels results in nearly 4 million premature deaths each year, caused by a range of deadly chronic and acute health effects. Diseases like child pneumonia, lung cancer, chronic obstructive pulmonary disease, and heart disease plague communities in which mothers and children primarily are regularly exposed to cooking fumes. When you add all those deaths up, a simple act like cooking dinner becomes the fourth greatest risk factor for disease in developing countries.

Traditional/crude cooking technology in one of the primary schools in remote/rural Uganda.

                Improved cooking technology at the same primary school.

Photos provided by; Edward Otim, Program manager/Global Health Corps fellow at USAID-SDS Program.

In addition to these serious health effects, this method of cooking also has serious environmental implications. Traditional cooking fires and stoves are highly inefficient and contribute significantly to the rapid depletion of local natural resources in these areas. This depletion can contribute to climate change thus posing significant health effects including irregular water supply and malaria out breaks as a result of flash floods. Subsequently, this forces rural and impoverished families to resort to drinking the dirty, sediment and parasite laden water that sits in puddles and small pools on the surface of the earth.

The great thing is that there is an incredibly easy solution. Cleaner stoves and high-efficiency stoves as indicated in the above photo are cheap and available to families across the world. The adoption of these cleaner stoves will not only save millions of lives a year, but will also reduce the risk of natural resource depletion and its associated health consequences.

In the meantime, families can work to transition their cooking environments to cleaner and healthier areas by using chimneys, insulated heat cookers, increasing indoor ventilation, and cooking outdoors. While these simple solutions won’t solve every problem, they are an important step towards protecting those in need.

If we are to concretely ensure that global health equity is achieved by all, we should start to re-channel a greater percentage of our efforts to these so called “innocent” and “silent” activities that are eroding a big part of our populace rather than investing all of our focus on the rather obvious causes.