1. Breanna Goodwin, MSII

2.  Explain why sustainability is important in any development project  Address aspects of international health care that create barriers to health care at the level of the care provider  Discuss the significance of medical tourism

3. Sustainability

4.  Aid  Appropriate/Inappropriate Use  Unethical Use

5. “A ghost school might be a school which is not there, it never was built, and they said ‘oh we’ve built the school’ and there’s actually no school there,” said professor Anita Ghulam Ali, former Sindh education minister and head of Sindh Education Foundation, a government agency that works to address education issues in the province. “Then of course the usual, the most common one is where the school is closed and there are no teachers, so for all intents and purposes it’s a ghost school.”

6.  Medication Acquisition  Quality  Transport  Storage  Security

7.  Generic Drug Availability: “The OTHER Drug War”  Trade-Related Aspects of Intellectual Property Rights (TRIPS) provision of the WTO, 1995 “…which established minimum levels of protection for member countries for products including pharmaceuticals.”  Doha Declaration, 2001 Paragraph 4: “The TRIPS Agreement does not and should not prevent Members from taking measures to protect public health… [TRIPS] can and should be interpreted and implemented in a manner supportive of WTO Members' right to protect public health and, in particular, to promote access to medicines for all.”

8.  Generic Drug Availability: “The OTHER Drug War”  Compulsory Licensing “In essence, under compulsory license, an individual or company seeking to use a patent can do so without seeking the patent holder's consent, and pays the patent holder a set fee for the license.” These tend to be issued for specific drugs, not entire drug classes; the licenses are also normally granted for communicable diseases. Countries issuing compulsory licenses include Germany, Canada, the United States, Brazil, Thailand, Malaysia, Cameroon, Eritrea, Mozambique

9.  Generic Drug Availability: “The OTHER Drug War”  Role of pharmaceutical companies Many argue that defense of patent rights in part determines whether new drugs will be developed. Some also argue that the countries have the resources to afford the prices, but choose to allocate money elsewhere. Some have vowed to withhold all new drugs from any country seeking a compulsory license. In 2007, Abbott Laboratories (Illinois) abandoned plans to release new drugs for hypertension and AIDS in Thailand as a response to the government’s issuance of a compulsory license for Kaletra, a second-line AIDS medication.

10.  Generic Drug Availability: “The OTHER Drug War”  Role of wealthy countries “Rich countries have failed to honour their promises. Their record ranges from apathy and inaction to dogged determination to undermine the declaration's spirit and intent. The US, at the behest of the pharmaceutical industry, is uniquely guilty of seeking ever higher levels of intellectual property protection in developing countries.” —Oxfam, 2006 “Governments and public institutions must bear primary responsibility for safeguarding equitable and quality access to essential medicines around the world.” —Dignitas International, 2011

11.  Generic Drug Availability: “The OTHER Drug War”  Role of Wealthy Countries “[The Clinton Foundation] negotiated deep price reductions for generic versions of costly, second- line AIDS drugs… [Mr. Clinton] also forcefully endorsed recent decisions by Thailand and Brazil to break patents held by American pharmaceutical companies… But developing countries still have reason to worry about retaliation from drug companies and trade sanctions by the United States…United States trade officials last week put Thailand on a watch list for countries inadequately safeguarding the intellectual property rights of American companies, noting the overriding of drug patents.”

12. Empowerment of the poor, human rights Access to medicines, global health funding, human rights

13.  Changing medical needs  Drug resistance Malaria (Plasmodium falciparum), on specific rise in Southeast Asia MRSA Shigella resistance to Cipro Neisseria gonorrhoeae resistance to cephalosporins Tuberculois “About 440 000 new cases of multidrug-resistant tuberculosis (MDR-TB) emerge annually, causing at least 150 000 deaths. Extensively drug-resistant tuberculosis (XDR-TB) has been reported in 64 countries to date.” –WHO, 2012

14.  Medical Supplies  Testing Materials mChip: 10 detection zones, requires a pinprink of blood, may be read by the naked eye. Cost: US$1.  Exam/Surgical supplies

15.  Food Supply  Price of food and amount of those hungry are directly proportional Since July 2010, “prices of maize increased 74%; wheat went up by 84%; sugar by 77% and oils and fats by 57%.” (Oxfam) 925 million in chronic hunger throughout the world as of 2010 (FAO)  Poor people in developing countries spend between 50-80% of their income on food. (Oxfam)  Luckily, experts have stated prices are no longer rising, and it is unlikely for a repeat of 2007-2008 (which saw civil unrest due to food issues) to occur.

16.  Food Supply: Implications of Trade Agreements  NAFTA/FTAA While NAFTA has been largely successful in increasing overall wages in Mexico, as well as being correlated with a increased level of skilled workers remaining in that country, the great influx of cheap American corn has displaced southern Mexican markets.  Mercosur Bloc This year, Mercosur admitted Venezuela into its trade bloc. It can be hoped their food shortages will be reduced due to its new membership.

17. Level of the Care Provider

18.  Availability  Support and Collaboration  Perception  Safety  Endurance

19.  Migration  Many poorer countries face migration issues, as those trained in health care will often center in an urban area or immigrate to a wealthier country. WHO Global Code of Practice on the International Recruitment of Health Personnel  Recruitment and Training  Encouraging able nationals Community leaders, students  Specific, limited training Addis Ababa Fistula Hospital

20.  Retention  Working Conditions and Safety Living Situation Leadership Encouragement  Stress/Frustration/Burnout/Depression  Compensation

21.  Support and Collaboration  Public Health Sector: “Investing in the Commonwealth” Many NPO’s work within a country without ever contacting the government itself. “…[W]hat we did 10 years ago was to decide that all of our expansion would only occur in the public sector. So what that meant would be we wouldn't build our own hospitals or clinics but rather rebuild or build public-sector clinics and move our staff into those clinics and facilities and try to beef up the public sector that way.” —Paul Farmer

22.  Support and Collaboration  Setting Standards – WHO vs UNICEF – Direct competition for funding/project success using their techniques/protocols. Overlooked Programs – When NGO/NPOs enter a country, they sometimes overlook the currently active programs in the region.

23.  Cultural Competency  To be discussed more in-depth later in the semester  “White Doctor Syndrome”  For various and sundry reasons, patients may trust certain expat physicians due to their phenotype and/or country of origin

24.  Disempowerment of In-Country Staff  Communities receiving repeated aid report they trust their NGO/NPO doctors more than their local doctors, despite equivalent care.  “These foreigners show up with their shiny new equipment and do their free surgeries without ever working with any of [the Guatemalan physicians]. US doctors come to Guatemala and practice medicine when and where they want. Guatemalan doctors may have a hard time even entering the US, let alone being able to practice medicine there. US physicians are not superior to Guatemalans. I am perfectly capable of taking care of my own people.”

25.  Staff Security  In 2008, 260 humanitarian aid workers were killed, kidnapped or seriously injured in violent attacks – the highest yearly toll on record. The sharpest increases in attack rates have been suffered by international (expatriate) staff of non-governmental organizations (NGOs). Countries with Highest Numbers of Aids Workers Killed (1997-2003) Angola58 Afghanistan36 Iraq32 Sudan29 DRC18 Rwanda17 Somalia16

26.  Aid in Wartime  ICRC in Libya ICRC in Libya  Female Workers  In many areas of the world, rape has become a weapon of war. This can extend to any female— national or expat, health care provider or not— encountered in a situation where rape has become acceptable.  Fighting Suspicions  Pakistan, Save the Children, and the CIA

27.  Burnout/Depression  Long hours  No privacy  No personal space  Poor hygiene (not always the case)  Away from family/friends  Facing extreme suffering, poverty, advanced disease, malnutrition, neglect and abuse on a regular basis.

28. Medical Tourism

29. “Medical tourists often have little experience in developing world settings and often combine medical visits with recreational or cultural activities. Although medical tourists are often motivated by genuine altruism, they often overestimate the need for their assistance or the utility of their specific skill set to problems they encounter. Medical tourists may bring much needed medical supplies or expertise, but they may also inadvertently undermine local health-care infrastructure or provide inappropriate, incorrect, or even harmful medical care.” —Barry Pakes, Encyclopedia of Global Health

30.  Skill-Building  “You are not useful until you have been trained…There is no place for untrained fistula surgeons who set out on their own to learn repair techniques by trial and error.” —Wall, et al (2006)  Oversaturation  Many aid workers were stranded at airports awaiting flights into Haiti or transportation into areas within Haiti after the 2010 earthquake.

31.  Respect  Photography and professionalism

32. “If you must go, focus on one country or region: learn the local language, and learn about the local health problems, as well as the systems of traditional and introduced care. Respect local cultural norms. Do not further propagation of US-centered, global monoculture. Consider your strengths and what you have to offer. Teach appropriate skills using the limited locally available resources, and sign up for the long haul, at least in spurts. Meanwhile we have a lot more work to do at home.” —Dr. Stephen Bezruschka

33.  Make maintenance of primary importance:  Service of generators, vehicles, refrigerators, knowledgeable staff, reliable translators.  Exercise crowd control  Under-promise in order to over-deliver  Respect established protocols (if effective and ethical), as well as all staff members  Encourage and empower those present in the country to the best of your ability  Be self-aware