CIAO DATE: 12/2010
Volume: 27, Issue: 2
Summer 2010
To Protect & Cure (PDF)
For more than two millennia, physicians have been healing patients—pledging to protect and cure under the terms set forth by the oath Hippocrates crafted nearly 500 years before Christ. Today, doctors have at their disposal methods of diagnosis and treatment unparalleled in the history of mankind. We can cure blindness, scan the brain and operate on a beating heart. And yet, there has never been such disparity between the care that is possible and the care that most people on earth receive. How our medicine is distributed—the treatment and personnel necessary to deliver it—is one of the greatest challenges facing the world today. The challenges are scientific, political, social, religious and economic—after all, healthy people are happier and more productive, and the benchmark of a successful society.
The Big Question: What is the Most Pressing Health Crisis and How can it be Solved? (PDF)
Devi Sridhar, Ernest C. Madu, Jeffrey L. Sturchio, Adel Mahmoud, Ariel Pablos-Mendez, Guy Carrin, Benjamin Mason Meier, Michael E. Gyasi
A preventable disease like malaria, eradicated in high-income countries, still causes one million deaths in developing nations. As India adds more millionaires to the world than any other nation, 40 percent of its children are undernourished. There are fundamental inequalities in global health. Ultimately it is up to governments to ensure a healthy population: safe water and sanitation, adequate food, education and health care services, and a conflict-free environment. Within governments, ministries of health are tasked with illness prevention and treatment; but often the most important determinants of overall health lie outside their purview. In Kenya, for instance, preventing malnutrition requires coordination and cooperation from the ministries of agriculture, water and irrigation, co-operative development, and finance. Since each individual ministry isn’t primarily concerned with malnutrition, they have little incentive to allocate their limited financial and human resources for this goal. The public health and sanitation ministry is then left scrambling to treat the diseases their administrative cohorts could have stopped. To fix this, an inter-ministerial working group on health should be formed in order to streamline health care in relevant sectors. Most important, the ministry of finance needs to allocate sufficient funds specifically for disease prevention. Then, we can start heading in the right direction.
The Next Pandemic (PDF)
John M. Barry
It is the nature of the influenza virus to cause
pandemics. There have been at least 11 in
the last 300 years, and there will certainly
be another one, and one after that, and another
after that. And it is impossible to predict
whether a pandemic will be mild or lethal.
In 1997 in Hong Kong, the H5N1 virus
jumped directly from chickens to 18 people,
killing six. Public health officials slaughtered
hundreds of thousands of ducks, chickens and
other fowl to prevent further spread, and the
virus seemed contained. It wasn't. In 2004,
H5N1 returned with a vengeance. Since then, it
has killed hundreds of millions of birds, while
several hundred million more have been culled
in prevention efforts. And it has infected more
than 500 human beings, killing 60 percent of
those infected. The virus's high mortality rate
and memories of the 1918 influenza-the best
estimates of that death toll range from 35 to
100 million people-got the world's attention.
Every developed nation prepared for a pandemic,
as did local and regional governments and
the private sector. They all based their preparations
on a 1918-like scenario, but it did not
come. It still could.
Bitter Pills: Islamist Extremism at the Beside (PDF)
Qanta A. Ahmed
LONDON—Afternoon dissolves into evening. I peer out of my office in the Royal London Hospital, spying the window that once framed the Elephant Man. A century later, a new and equally grotesque spectacle enthralls—in the street below, a well-fed British-Pakistani distributes cassettes. Transplanted Wahabi women, black-gloved, clad head-to-toe in black abbayas, faces masked by niqabs, snatch the recordings, nodding brief salaams. Other women, too busy, rush by in damp, rain-streaked chadors. I watch the figures until they disappear into the dank Whitechapel tube station. Muslim men stuff the cassettes into their grubby Adidas jackets, worn over thobes, the traditional Arab male dress. Only a sprinkling of stolid British police officers reminds me that, under the lapping October tides of Western European Islamofascism, this is still London.
India on less than $30 a Year (PDF)
Sandhya Srinivasan
MUMBAI, India—Shanta had a good life for a working class woman in Mumbai. Her husband Manoj was a watchman in a factory compound in a western suburb, and they lived in a room with running water, free electricity, even firewood for cooking. She commuted to work, an hour each way, into south Mumbai, where she cleaned three households. But in 2007, Manoj suffered a stroke, and though they went to a municipal hospital for treatment, they spent thousands of rupees (hundreds of dollars) on prescriptions. Shanta became the sole earner and they continued to spend on local healers. Then, Shanta was hospitalized for a severe bout of falciparum malaria (a virulent strain of the mosquitoborne disease, once limited to northeastern India, but now common in Mumbai). Recently, Manoj fell and broke a hip and required surgery, which cost $426 for subsidized treatment at a municipal hospital. To put that number in perspective, the monthly per capita income for 80 percent of the urban population is less than $42. In Shanta’s case, the cost of her husband’s hip surgery was four months’ wages.
Brazil on $300 a Year (PDF)
Jeb Blount
to Lourdes’ annual departures. Our maid’s happy chatter would transform into vague grumblings and complaints about dores nos ossos—the pain in her bones. She’d start in on her cachaça-drinking husband, the alcoholic, and her many humiliations at the hands of the mouthy, pregnant teenage girls who roam Caju, the drug gang-dominated Rio de Janeiro slum, or favela, where she lives. Lourdes would say she missed her elderly mother in Paraiba, a poor state in Brazil’s northeast. She’d say it was time to retire. Then we’d pay her and chip in a few extra hundred reais for the four-day bus ride to Paraiba and she’d leave.
France on $3,000 a Year (PDF)
Hala Kodmani
PARIS—In the visitors’ book of the exhibition “Humanization of the Hospitals,” one recent comment observed: “In this museum you’re in a dream...It’s so different from the hospital I have to return to next week.” This exhibit of what French hospitals ought to be is essential. The French public may seem like they are all too often persuaded that their health care system—so praised and envied abroad, held up as an example even among other developed countries—is one of the best in the world. This isn’t the case.
Lethal Counterfeits (PDF)
Paula Park
The border between Thailand and Cambodia is a petri dish for drug-resistant strains of malaria. Scientists believe that in this region, more than 50 years ago, parasites that cause the disease mutated to fight a common antimalarial drug, chloroquine, and multiplied. People carried these new parasite strains across the world, spreading the drug resistance. Today, these same borderland parasites show new signs of resistance. This time, it’s to a combination of drugs, including one called artesunate, that had, until recently, made inroads against the spread of the disease. In 2004, the Cambodian government found that nearly one in five cases of artesunate sold by retailers in four provinces bordering Thailand lacked sufficient amounts of the active ingredient. Six years later, Cambodian health officials cracked down on the distribution of these counterfeits. By April 2010, officials had closed two-thirds of the country’s 1,081 illegal retail shops, the main sellers of fakes.
There Are No Quick Fixes (PDF)
Dr. Sam Zaramba
Dr. Sam Zaramba is chairman of the executive board of the World Health Organization (WHO) and served as the Director General of Health Services in Uganda. As an early advocate for integrated disease control, Dr. Zaramba is credited with the success of the “Child Health Days Plus” campaign in Uganda, which included a deworming program and vitamin distribution for children. He initiated several other public health related projects including routine immunization, health and hygiene education, and distribution of insecticide soaked nets. Dr. Zaramba has also published a number of articles on neglected tropical diseases, such as river blindness and sleeping sickness. Trained in Uganda as a physician, he retired from his post as the country’s top medical officer and now devotes much of his energy to the WHO, the United Nations agency overseeing its global health strategies. He spoke with World Policy Journal from Geneva, where the WHO has its headquarters.
Ghana: The Waste Land (PDF)
Frankie Freeman
ACCRA, Ghana—It’s 7:30 a.m. and the sun is rising fast over Ashaiman. Open gutters steam at the side of the road and the air is alive with the sounds of the crowded Accra suburb waking. Women fry meat over wood fires while the clatter of their cooking cuts through the morning. Patrick Apoya, former executive secretary of the Coalition of NGOs in Water and Sanitation, drives to meet a colleague. His white Toyota pickup truck crawls through the crush of workers on their morning commutes. He loosens the collar on his pressed cream shirt and leans a broad forearm out the window, drumming his fingers on the car’s warm metal. He has been driving for 30 minutes and is dressed for an air-conditioned office. Frowning, Apoya wipes a bead of sweat from his brow. Five minutes from his destination, Apoya sees a crowd gathered around a neatly dressed young man. They are standing at the concrete entrance to a shabby public toilet. A fight is about to break out.
Palestine: From the Rubble, Life (PDF)
Eman Mohammed
GAZA, Palestinian Territories—Between the shattered memories of the past and an unknown future lies a pile of rubble that is called home. Mohammed Khaderi, his wife Ebtesam and the 22 members of their family live here, in the heart of Gaza. Their house was targeted by Israeli field operations and all but leveled during the last incursion into the Gaza Strip—the 2008-2009 war. Ever since, the Khaderi family has lived beneath a makeshift tent attached to what remains.
The Last Yakuza (PDF)
Jake Adelstein
TOKYO—In June 2007, as Japan’s upper house elections were drawing near, the nation’s largest organized crime group—the 40,000 member Yamaguchi-gumi—decided to throw its support behind the country’s second leading political party, the Democratic Party of Japan (DPJ). Fifteen of the Yamaguchi- gumi’s top-ranking members made the decision behind closed doors. After the die was cast, a meeting was convened at the sprawling Yamaguchi-gumi headquarters, which take up two square blocks in Kobe. The gang’s most powerful executive members, the jikisan, were summoned from throughout Japan and ordered to put their full support behind the DPJ. The message was simple. “We’ve worked out a deal with a senior member of the DPJ. We help them get elected and they keep a criminal conspiracy law, the kyobozai, off the books for a few more years,” one insider said. The next month, calls went out from Yamaguchi-gumi headquarters to the heads of each local branch across the country. In Tokyo, even the conservative boss Goto Tadamasa, leader of the 1,000 strong Yamaguchi-gumi unit called the Goto-gumi, told his people, “We’re backing DPJ. Whatever resources you have available to help the local DPJ representative win, put them to work.” Bosses of the Inagawa-kai, Japan’s third largest organized crime group (10,000 members), met in an entertainment complex they own in Yokohama, and announced to board members that the Inagawa-kai would support DPJ as well. At the same time, the yakuza allegedly struck a deal with Mindan and Chosensoren— political and social organizations that lobby for the rights and interests of Japanese of Korean descent—to support the DPJ. Party leaders, in turn, promised both groups that they would strive to get Japanese- Koreans with permanent residence equal voting rights when they took office. According to the National Police Agency [NPA], of the more than 86,000 yakuza members in Japan, a third are of Korean descent.
Abkhazia on Three Wheels (PDF)
Alexander Cooley, Lincoln Mitchell
SUKHUMI—The land between Georgia and this breakaway region represents a tense coda to a short war and a tenuous peace, a tribute to the fragile nature of such territories. Here, the frontier post is considered an international border by the Abkhaz and is patrolled by Abkhaz troops. Russian forces are camped nearby. After Russia and Georgia’s brief war in 2008, Moscow recognized Abkhazia and South Ossetia’s declarations of independence. Since then, Abkhazia and South Ossetia have, with the Kremlin’s support, lobbied for others’ recognition but have, for the most part, failed. The territories are internationally isolated and increasingly dependent on Russia for security, hence the Russian troops. A steady stream of tired residents from Gali, an ethnic region on the Abkhaz side of the checkpoint, cross this frontier with shopping bags filled with goods for trade. By an unfortunate confluence of geography and politics, they are caught in between.
The Forever War: Inside India's Maoist Conflict (PDF)
Megha Bahree
CHHATTISGARH STATE, India—It was 4 p.m. one March afternoon in 2008. The victims were living in a relief camp in a village called Matwada. Two dozen members of a government-backed civilian militia, accompanied by at least one police officer, burst into their homes. They dragged four men out onto the street, across from a paramilitary office, and began to beat them with sticks. They paused to pour water over the Matwada men, waking them when they fainted out of pain and fear. When their wives flung themselves across their husbands’ weakened bodies, they were beaten too. Then the men were dragged from sight, into the forest. One managed to escape. The next day the remaining three were found buried next to a stream, stabbed in the eyes and the neck and finished off with a knife stab to the head. The men were suspected of being informants, of aiding the nascent Maoist insurgency in the eastern Indian state of Chhattisgarh. The survivor and three widows filed a criminal case against the state, and a court decided recently that the State of Chhattisgarh would compensate them for the wrongful attacks.
So Europe Ends at the Bosporus? (PDF)
David A. Andelman
There is one largely unheralded, and outside its own frontiers probably little mourned, casualty of the European crisis of confidence— Turkey. In its decades-long aspiration to become a member of the European community, this nation on the fringes of the continent’s southeastern frontier has played the part of the poor little orphan boy, nose pressed firmly against the glass shop window filled with sweets. Somehow, Turkey, despite its most valiant efforts, has never managed to find a way inside.