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Tuesday, June 10, 2008

On the politics of health

Scott was called by the top elected official in the district to join with the district health leadership and all other NGO’s in evaluating progress in the fight against AIDS.  He carefully compiled the numbers, extrapolating population data and comparing statistics from the health centers to show that our HIV prevalence among pregnant women remains low (3% or slightly less), but the Kwejuna Project has had a significant impact on the care those women receive.  Since its inception four years ago, the percentage of women in Bundibugyo who receive any prenatal care has risen from 49% to 72% (we were actually up to 80% pre-ebola, so have some lost ground to recover this year).  That’s 72% of 13 thousand pregnancies . . . A lot of women.  The percentage of women coming for prenatal care who were tested for HIV went from 0% to 98% in the first two years and now hovers in the mid-80’s (slippage in interest and supply shortages).  The number of male partners tested has increased from 8 (yes, 8 men in the whole district) to over 2,000 . . . Still less than half of new fathers, but a steep incline that indicates major shifts in practice.  Pre-Kwejuna men were never even seen within a mile of a prenatal clinic!  But perhaps the statistic that most significantly indicates a strengthening of health capacity in our district:  health-unit based deliveries have tripled in number and risen in percentage of all deliveries from 19% to 33%.  Most women still deliver in their mud-walled homes alone or attended by their mother-in-law, but more are accepting the oversight of trained midwives in a half-dozen equipped birthing centers.  In a place with high maternal and neonatal mortality, this trend has the potential to save hundreds of lives every year.

At the same time, major world AIDS programs had convened meetings today in New York, a far cry from the Bundibugyo conference.  I heard on BBC tonight that while progress is being made, less than a third of people who need to be on anti-retroviral drugs world-wide have access to treatment.  New infections still outpace capacity for care.  Countries like Uganda can not meet demands, though they spend almost 10% of their budget on health (relatively more than the US) the actual outlay per person is very very low.  Nation-wide the doctor:patient ratio is two hundred times thinner than in the west; in Bundibugyo it is two thousand times more desperate.  And so we struggle on, seeing some hopeful mile markers passing,  but painfully aware of the distance still to run.

Scott’s meeting started two hours late (surprise) which was not just the lethargy of Africa-time.  Instead, a peaceful protest had disrupted the town.  Demonstrators spoke and marched against the new government policy to spray houses with DDT as a way to combat malaria.  Here the politics of health becomes very murky.  Will small amounts of residual DDT lead to environmental catastrophe, as in Silent Spring?  How does a country weigh environmental cost against the deaths of thousands and thousands of children from malaria?  Is sounds very politically incorrect to support DDT . . . But most of those voices come from places like America, where we no longer fear malaria, because we wiped out the anopheles mosquito.  Is it fair to forbid Uganda to do the same?  While I would like serious data to wrestle with these questions, the protestors had more practical concerns. Over the last decade Bundibugyo’s economy has been driven by cocoa.  It is now a major cash crop.  And the biggest cocoa buyers have made it clear that if any DDT is sprayed anywhere in this district, ALL farmers will lose their “organic” certification.  As Luke pointed out, being “organic” is one of the only things that Bundibugyo really has going for it, one of the few up sides of isolation and poverty.  The price per kilo of cocoa would be almost cut in half if the organic label is removed.  That means almost half of most family income would disappear. So will the health benefits of decreasing malaria transmission be lost in the doubling of poverty?  A very reasonable question.

Health is a political concept.  Today’s protestors were arrested as anti-government, since there is no real distinction between policy and person.  Disagreement is equated with disloyalty.  The wisdom of Solomon is needed for these impossible choices, for parents who are trying to survive by choosing between the income that allows them to pay school fees for their older children, and the marlarious soup that drives the younger ones into disease and all too often death.  A cruel irony that choosing against spraying may mean that the very child whose education the cocoa-money would have funded may instead be the next one in a coffin.  

5 comments:

Unknown said...

Maternal and child Health is of utmost importance.
Its startling to know that more than half a million women die in pregnancy and childbirth
every year - that's one death every minute. I also came across a community on orkut which
represents the UN campaign against poverty of which child and maternal health is one of
the 7 major goals.

Ed Darrell said...

Who are the "biggest cocoa buyers," and why do they claim their purchasers are such blooming idiots?

Nick Jesch said...

The saddest part of the DDT issue is that the whole thing seems to have been based on junk "science". The rallying cry back in the day was the Brown Pelican, whose egg shells were too thin--blamed on DDT molecules found in their body fats. NO ONE has ever shown any evidence of a link..and forty years on, when DDT residues in California are all but nonexistent, guess what? The Brown Pelican is still threatened, and still have thin egg shells. Yet the world is dying of malaria because we fear a "silent spring". Same thing with R-12 refrigerants "shooting holes in the ozone layer" (but can anyone riddle me why ozone is considered a pollutant if it is in danger of disappearing...?) and the present "carbon dioxide greenhouse gas" folly.

I also have a hard time swallowing the "half price" scare threats. I deal in coffee, and the price difference I pay between organic (most often inferior in quality) and not-certified is minimal..ten percent at best. Perhaps its time the local cocoa growers come together, throw off their oppressive middlemen, and deal directly with world importers. Many coffee growers have done, and are better for it. It amazes me how so many world tragedies find their roots in the profit motives of the unscrupulous. Who profitted from the removal of DDT and R-12 from the marketplaces? The chemical manufacturers who stood to make massively larger profits from their replacement products, that's who. As ever, follow the money.
Praise God for people like yourselves whose heart is truly for the small people who have none other to stand in the gap for them. One more detail, and I'm done. I am fairly familiar with organic certification proceedures, and I've a hard time swallowing the "fact" that using DDT anywhere in the district will immediately lead to the end of certification for the entire districe. Someone is playing the bully here. That does not fit with what I understand of the process and requirements. Residues of the chemical would have to be documented IN THE SOIL of the producing area, and each one coming up for recertification will have to be tested...as always. Only those with documented residues could possibly stand to lose their certification. Unless the entire district is "certified" (never in MY knowledge), in which case all use of oil and chemical spweing vehicles (which means all of them...) would have to cease.

Anonymous said...

What are the alternatives to DDT, to protect the price for organic cocoa? Mosquito nets?

Interesting point about hypocrisy - should Uganda be allowed to wipe out that mosquito now to protect future generations from malaria? That's one I'll think about, for sure.

Ed Darrell said...

Actually, the brown pelicans in the U.S. have recovered nicely, in exact correlation to the drop in residual DDT in their tissues. There is a fair deal of research available on that issue.

Who in the U.S. is asking Uganda not to spray DDT? Even Environmental Defense is on record supporting limited spraying indoors, in Indoor Residual Spraying (IRS) -- which is significant because ED is the group that first sued to stop spraying on Long Island, north of New York City. I keep hearing that "American environmentalists" oppose DDT, but no one can tell me who they are.