SPECIAL INITIATIVES
GLOBAL HEALTH EQUITY
Much of the global burden of disease and injury is caused by factors tied to inequity. Discrimination blocks the delivery of health services to those in greatest need, unlawful practices allow counterfeit and substandard drugs to flood markets with impunity, and the violation of municipal regulations allows injury and disease linked to environmental causes. These additions to the global burden of disease are knowable and measureable, as are the impact of targeted interventions to address them. For more than ten years, EWMI has taken rights-based approach to its support of local organizations and government agencies in the area of global health equity. EWMI programs in nearly a dozen countries work in areas often overlooked by traditional health programs, and address the inequities that can be missing pieces in some of the most intractable health issues.
India’s Dalits (so-called untouchables) make up sixteen percent of the national population, some 200 million individuals living at the margins of society. Despite the abolition of caste discrimination in the Indian Constitution in 1950, Dalits have been regularly excluded from public life – including unlawful discrimination at health centers, where exclusion occurs at a rate of 10% according to a recent comprehensive study of untouchability practices. With more than 25 million Dalit children age six and younger living in India, a 10% exclusion rate from access to health services translates into millions of children missed: a grave risk to the goal of polio eradication. Unfortunately, accounts from villagers provide evidence that the history of systematic discrimination faced by Dalits also extends to polio vaccination campaigns today, with many Dalits either avoiding vaccination, excluded from vaccination, or both.
EWMI launched a pilot monitoring program with its local partner in Gujarat, the Navsarjan Trust, to map and address this problem. The monitoring program involved surveys of more than 3000 mothers and children to determine the extent of the problem of missed Dalit children. Because health center discrimination, or a fear of such discrimination leading to avoidance, is part of long and sensitive history of fraught caste relations, EWMI works with the Dalit community activists – including the state-wide network of Gujarati “barefoot lawyers” – to independently monitor the scope of the problem. These advocates are well-versed in legal protections, and sensitivities in rural Dalit communities, and have a presence in 3000 villages across the state, allowing unique access to Dalit neighborhoods and thorough coverage of a cross-section of districts. The pilot program was completed in 2012, and the results are guiding development of a broader Dalit polio vaccination monitoring program to be conducted in 2013.
On the Thai-Cambodian border, the parasites that carry malaria demonstrate a dangerous resistance to the most effective anti-malarial drug, artemisinin. Counterfeit and substandard artemisinin combined therapies (ACTs) carry much of the blame, and the illegal pharmacies that sell these fake drugs not only take thousands of lives in Southeast Asia, but threaten anti-malaria efforts throughout Asia by breeding new ACT-resistant mosquito-borne parasites.
With funding from the USAID/Cambodia Health Office, EWMI, working with the Cambodian Ministries of Justice and Health, has launched research and training efforts with the nation’s judges, prosecutors and health officials to strengthen investigation and prosecution of the purveyors of counterfeit and substandard ACTs, as well as TB drugs. Without effective prosecutions, police efforts to shut down illegal pharmacies can only go so far – convictions are necessary to stop the push-down pop-up effect that sees offenders continuing their trade across town. EWMI began its artemisinin resistance control efforts in 2012 at the epicenter of the problem: launching its research and training program through work with magistrates from the key border provinces of Pailin, Battambang, and Bantey Meanchey.
In Cambodia, while HIV infection prevalence has reached a stable .5%, the infection rates of high risk groups continue at alarming levels. With IV drug user rates estimated as high as 35%, and sex workers at 14%, break-out risks for the broader population remain. One of the main conduits for this risk is Cambodia’s overcrowded prisons: they lack in proper care for people with HIV, and are also a source of disease transmission.
EWMI and its partners have worked with legal aid lawyers, prisons, and the courts for several years to reduce prison overcrowding, with dramatic measurable impact on excessive pre-trial detention. In 2013 EWMI is planning new initiatives with UNICEF and the Ministry of Justice to guide IV drug users and sex workers toward the health care resources they need. EWMI also partners with local human rights groups like LICADHO to bridge care givers, justice sector officials, and the prisons in an effort to reduce the risk of a break-out of HIV, while increasing respect and care for these vulnerable groups.
