Video of Samson Njolomole’s talk at Tufts University

Samson Njolomole began as an HIV+ patient seeking treatment in his home country of Malawi, but soon became involved in service to help other patients like himself. He began as a translator for Partners in Health but has since risen to become a leader in the community as HIV Program Coordinator and subsequently Community Programs Manager for PIH Malawi. His passion and drive have inspired people around the world and mobilized communities in Malawi to fight HIV/AIDS, malaria, maternal health issues and much more.

Click on the link below to listen to Samson’s talk as he speaks to the Tufts community.

https://drive.google.com/file/d/0B1EcY7vQYe45bmR6SGtrcFl5WFk/edit?usp=sharing

The Stigmatization of HIV

When Samson Njolomole came to campus last Monday, April 7, he spoke to a crowd of about 100 students interested in his work as the External Relations Manager of Partners in Health in Neno, Malawi. Njolomole began his speech with the revelation that he was HIV positive. The audience, of course, responded with respect; yet, in his home in Malawi, this may not always be the case. Rather than compassion, many HIV positive individuals are shown contempt and possibly even shunned by their community. There is a prevailing societal view that their condition is their own fault, indicative of some kind of deviant behavior. Thus, their healthcare and treatment are not prioritized. This attitude brings to mind the words of Paul Farmer: “The idea that some lives matter less is the root of all that’s wrong with the world.”

Njolomole spoke of his personal experience through his diagnosis, and how he grew very ill, so much that his own mother couldn’t recognize his voice on the phone. He spoke of being coldly dismissed from his job because he was too sick to work efficiently. He told the crowd about how when his father finally suggested he get tested, Njolomole had the same reaction as many of the others: shock and embarrassment. “Not me.” These are the emotions that stop people from getting screened and even treated. They know the way society will receive them and this stigma only induces more severe health consequences.

Along with his own story, Njolomole shared some of the instances of stigma he had observed. He spoke of seeing a sick man being brought to the hospital, and how observers on the street were plugging their noses and complaining that he smelled bad. Unfazed by this man’s misery, these people were bothered by his stench. To bystanders, this ill man was not a pained human, but simply an irritating and unpleasant scent. Njolomole, a dynamic speaker naturally, became increasingly passionate and even angry – rightfully so – as he described the degrading treatment he has both experienced and observed.

When expressing his outlook on life, Njolomole described a man with a pinch in his shoe. He walks a little funny because of it, and people laugh. They don’t ask why he is limping, what causes his behavior. Njolomole sees this as the problem; too often people discriminate against those living in terrible circumstances, rather than listening, empathizing, and trying to lift them up. But through his work with PIH, he has seen improvements. The organization has constructed a hospital in Neno, and another in Lisungwi. PIH also provides support to eleven community health centers throughout the district. Prevention and treatment of HIV are two of many health initiatives taken on by the centers. They’ve even gone a step further by developing a community outreach program for HIV positive individuals, which provides education and a sense of community for them. We must hope that through projects like these, and with the guidance of strong and intelligent individuals like Njolomole, the HIV stigma will begin to subside.

Holistic Health and Wellness: A Different Approach to Healthcare

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I believe it would be safe to claim that all human beings are enthusiastic, and therefore more motivated, when we have energy and excitement for the life we are living. When we experience these positive sentiments, they causes us to be more motivated, which it becomes positive and cyclical. This cycle of positivity and wellness is the key ideas in the movement of holistic health and holistic medicine. Defined by the American Holistic Health Association, holistic health is “…actually an approach to life. Rather than focusing on illness or specific parts of the body, this ancient approach to health considers the whole person and how he or she interacts with his or her environment. It emphasizes the connection of mind, body, and spirit.” The article goes on to explain that rather than take health care one step at a time when a problem arises, the goal is achieving maximum well-being in all areas of life including mental, physical, and spiritual health.

Records show that holistic health practices have been around for thousands of years in various parts of the world. Most significantly, however, these practices have been noted in India and China as far back as 5,000 years ago when practices centered around living a healthy lifestyle “in harmony with nature.” Holistic health concepts began to lose momentum in the western world around the 20th century, and now, with advanced technology and modern medicine, it is widely believed that one can sustain a healthy lifestyle by allowing modern medicine to cure any ailments that arise from it.

I believe, however, that this practice is backwards. Optimum health in all areas should be the goal in everyday life, and there should be less of an initial instinct to turn to drugs for certain illnesses, and rather to mental health, nutrition, and natural remedies. Holistic practices include, but are not limited to: meditation, chiropractic therapy, massage therapy, acupuncture, naturopathy, and natural herbs and oils. In addition, the art of healing should be taken as an individual approach rather than simply viewing the person as an example of a specific disease or illness which are all treated the same. This approach should also emphasize patient-physician partnership and trust. Socrates, in 4th century BC, advised against solely treating and focusing on one part of the body at a time by stating, “the part can never be well unless the whole is well.”

Holistic health upholds the idea that all aspects of health are connected and affect one another, just as all aspects of life and the universe affect one another. Though this approach is ancient and still widely practiced in parts of the world, I strongly feel that we (especially the western world), has lost touch with it and this sense of connectivity. In turn, we have fostered a society in which pills are taken as a remedy for all ailments and preventive care is not considered priority. I believe that through the practices behind holistic health and complementary, alternative, and integrative practices different from modern western medicine, we can significantly improve our overall individual health, and by doing so can change our health care system for the better physically and monetarily. Our nation, and ideally world, would be healthier in all components of life, and therefore happier, which could foster a myriad of other positive changes.

Improving Maternal Health Outcomes in Rural Developing Areas

Every day approximately 800 women die across the world from preventable causes related to pregnancy and childbirth. These lost lives are not just a number, but they are a mother to a child, a wife to a husband, an aunt to nieces, and much more. The loss of the life of one woman, which is easily preventable, is a societal loss. The lost lives of tens of thousands each year in countries around the world must prompt a serious discussion on improving maternal health across the economic development spectrum of nations (Mackay, 2006). This past year, Globemed at Tufts has worked with Nyaya Health to fundraise money to alleviate any resource burden that pregnant mothers might face to access their right for antenatal care and delivery in Achham, Nepal. As we look forward to our new partnership with PHASE Nepal and its initiatives, we reflect on the endemic structural problems which present barriers to mothers accessing antenatal care and health-facility based delivery.

Complications through pregnancy periods can easily endanger the mothers’ and the child’s health and depend heavily on timely management and treatment. During pregnancy, the World Health Organization recommends at least four antenatal visits, which include tests to ensure the mother’s health as well as the fetus’s. However, the  major causes of maternal mortality are complications during birth itself, such as hemorrhaging, infection, high blood pressure, unsafe abortion, and obstructed labor.Institutional birth with trained and certified attendants at birth such as obstetricians, family medicine physicians and certified midwives, was a prominent factor in the decrease in the world maternal mortality rate between 1990 and 2010, during which, maternal mortality worldwide dropped by almost 50%.

Certain areas of the world have disproportionate encumbrance of maternal mortality: the burden of this mortality falls almost entirely upon the world’s poor, as 99% of maternal deaths take place in low-income countries (World Health Organization). Nepal’s government has recognized this fact and is working to implement a comprehensive strategy to reduce maternal health. In Nepal, a skilled birth attendant is present at a mere 36% of births (Kaiser Family Foundation, 2012), far below the recommended level. Demand for skilled birth attendants is high, but the actual supply of such individuals cannot meet the demand (UNICEF 2013). The major problem is funding: training future skilled healthcare workers requires a high investment, as does creating new facilities and supporting existing ones. However, a strong political focus on this goal, along with “sustained financial commitment from government and donors” over the past few years (Engel, 2013), has resulted in an increased number of skilled health workers along with improvement in access and quality of facilities.

The government’s attempts to improve maternal health resonate deeply at Nyaya Health, located in rural far western Nepal and Globemed at Tuft’s partner from 2010-2013. In the Achham district where Nyaya serves the population with free clinical care from Bayalpata Hospital, the best estimate of maternal mortality offered by delivery facilities is 800 deaths per 100,000 live births, a figure which is most likely an underestimate due to limited data collection among mothers and births occurring outside an institutional setting (Schwarz, 2013). This staggering figure dwarfs Nepal’s maternal health statistics as a whole, and is a result from the geography and other structural factors.

Achham, as one of the most underdeveloped regions of Nepal, exemplifies many of the problems of delivering care to a remote region. In Achham, villages and healthcare centers are often separated by mountains paved with roads with one lane each way; some poorly maintained and all treacherous in poor weather conditions. For most Achhamis, accessing clinical health care means walking, sometimes for hours. Pregnant women late in their pregnancy are unable to make the journey unassisted. Some of them are able to access buses or private motor vehicle transports, while others are reliant on stretchers carried by family or friends to bring them to the hospital. In both cases, the journey serves as a major disruption to the workday of both the mother and her immediate social network, which can be difficult for families who may feel that they do not have the resources to commit to an institutional delivery or regular antenatal care. This is not just a question of financial resources, but also social resources. This is especially important for the many migrant families in Achham, as many women who deliver while their husband is working abroad report having insufficient social capital to assist them in making the trip to the hospital (Nyaya 2013).

While there is still a lack of understanding about healthcare facilities and services available, awareness and health education is much better in Achham than it was four or five years ago, made possible by the Nepalese government’s efforts and also to the efforts of Nyaya Health. The government’s female community health volunteers (FCHVs), along with Nyaya’s Community Health Worker Leaders (CHWLs) are an integral part of providing primary healthcare services and raising awareness in Achham. More Achhamis than ever before are utilizing services such as the local government-run Health Posts and sub Health Posts, as well as Bayalpata Hospital’s services. However, maternal health offers a unique challenge. Most outpatients coming in to Bayalpata come for a specific issue or complaint which is often treated that day or with one follow-up treatment and then do not return. The four recommended repeat antenatal visits is a difficult commitment to make, because of the time commitment it takes. This is shown in Nyaya’s clinical data (Nyaya 2013).

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For every four mothers coming in for one antenatal visit, only one of them continued all the way to the fourth visit. In addition, there were almost 2.5 times as many institutional deliveries as fourth antenatal visits. These findings could have a few interpretations. Firstly, it is possible that while people understand the general principle behind antenatal visits, the difficulties of accessing repeat visits combined with a lack of immediate effect result in fewer people coming to repeat antenatal visits. On the other hand, a heavy educational emphasis by community health workers on the importance of institutional deliveries, combined with more visible and immediate benefits of having an institutional delivery as opposed to a delivery at home, may mean that many mothers who didn’t attend all four antenatal visits or any at all choose to deliver at the hospital because they recognize its importance. Another possible interpretation is related to the way Nepal’s incentives work regarding maternal health. In addition to training more healthcare workers, the Nepalese government offers individual incentives to mothers for antenatal visits is 100 rupees a visit, a not insubstantial sum in Achham, while deliveries are incentivized by 1000 rupees. For Achhami women weighing the costs and benefits of both delivering and receiving antenatal care, the onetime 1000 rupee incentive may make an institutional delivery much more attractive, while the 100 rupee incentive for antenatal care may not be enough for Achhami women to decide to receive antenatal care.

Despite efforts by the Nepali government and NGOs such as Nyaya Health and PHASE Nepal, maternal mortality remains high. In the end, it is up to the government, possibly in partnership with non-governmental organizations such as Globemed at Tufts’ partner, to design and implement a system to make sure all expectant mothers get the care that they deserve before, during, and after delivery. The path to achieving safe motherhood for all is arduous, but like most public health initiatives, it is worth taking. Nyaya Health, PHASE Nepal, and other organizations, in partnership with engaged citizenry and students such as those at Globemed at Tufts, remain committed to the challenge ahead.

References

Engel, J. (2013, ). A paradigm shift for maternal health in nepal  . The Overseas Development Institute

Mackay, A., Berg, C., King, J., Duran, C., & Chang, J. (2006). Pregnancy-related mortality among women with multifetal pregnancies. Obstet Gynecol, 107(3), 563-568.

Nyaya Health. (2014). Monthly data reports. Retrieved 02/23, 2014, fromhttps://www.dropbox.com/s/tusngngjmnvcz81

Schwarz, D. (2013). Maternal outcomes. Retrieved 02/23, 2014, fromhttp://wiki.nyayahealth.org/w/page/4682710/Maternal_Outcomes

The Henry J. Kaiser Family Foundation. (2013). Births attended by skilled health personnel (percent of births). Retrieved 02/23, 2014, from http://kff.org/global-indicator/births-attended-by-skilled-health-personnel/

UNICEF. (2013). Statistics on nepal. Retrieved 02/23, 2014, fromhttp://www.unicef.org/infobycountry/nepal_nepal_statistics.html

World Health Organization. (2012). Maternal mortality: Fact sheet. Retrieved 02/23, 2014, fromhttp://www.who.int/mediacentre/factsheets/fs348/en/

 

Repartnership

Dear Supporters of GlobeMed at Tufts,

As many of you have probably heard, GlobeMed at Tufts has recently announced a new partnership with PHASE Nepal.   While our partnership with Nyaya Health was very successful, Nyaya Health has entered a period of rapid growth and leadership turnover in Nepal.  Over the last three years, our chapter made an outstanding contribution of over $25,000 and sent two GROWS teams to Achham.  Unfortunately, due to their development as an organization, our GROW trips are unable to continue.  Despite our admiration and continued support for the amazing work that Nyaya Health does, GROW remains an integral component of the GlobeMed model and for this reason we chose to pursue a new partnership for the upcoming year.

We are very excited to announce the beginning of our partnership with PHASE Nepal.   PHASE was founded in 2006 by a group of dedicated individuals in Nepal and the UK with the vision to develop an organization that could take a truly integrated and cooperative approach to community development in Nepal.   Their ultimate aim is to create self-empowered and self-sustained society where all kinds of discrimination are absent.  Since its founding, PHASE has since grown to a medium sized professional NGO working in 18 communities with a staff of over 40 employees, and we hope that our chapter’s support will help them continue to grow and expand their amazing work.

PHASE Nepal has a very comprehensive development program and supports communities in the areas of maternal health, child health, family planning, health awareness raising, capacity building, community education, drinking water and sanitation, and emergency management.   We are very excited that our first GROW team and fundraising efforts will be focused on supporting their childhood education initiative.  Our GROW team will have the opportunity to work with schools directly to develop a health education program.   If you would like to learn more about our work with PHASE Nepal over the coming year please visit http://phasenepal.org/ and http://tuftsglobemed.wordpress.com/.

Thank You for your Continued Support,

GlobeMed at Tufts Executive Board

GlobeMed at Tufts is proud to announce our new partner, PHASE Nepal!

Standing for Practical Help Achieving Self-Empowerment, PHASE Nepal was established in 2006 by a group of professionals from different sectors of Nepal. PHASE Nepal’s approach is called Community Development Programme (CDP) and serves to empower both communities and individuals at every level. Invested in providing equal opportunity to eliminate poverty, PHASE Nepal is focused in three main districts: Sindhupalchok, Gorkha, and Humla. They are a non-governmental and non-profit organization that aims to help build “self-sufficient futures” for various remote villages in the Himalayan region of Nepal that lack access to basic health services. Their main objective to “improve the livelihoods of rural people by providing immediate support” falls within seven different components – basic health services, education, agriculture and forestry, gender and social inclusion, infrastructure development, strengthening institutional capacity of groups, and conflict mitigation and social justice.

We are so excited to work with them to break the cycle of poverty in the Himalayas through community efforts to promote health, education, infrastructure, agriculture, and social justice! Learn more about PHASE Nepal at http://phasenepal.org/

Overprescription of Opioids Epidemic

opioidsStarting at the turn of the century, an increased amount of data has shown, over an array of studies, that deaths by caused by drug overdose have increased for the fourteenth consecutive year, mostly due to opioid analgesics, which are “derived from the poppy and used for pain relief,” and include Hydrocodone, Morphine, and Oxycodone. Opioids are more readily being prescribed in the past decade than ever previously before by doctors to patients, often without consideration of the severity of their condition, their state of mental health, and alternative medications and options.Though providing therapeutic pain relief to millions of Americans, this staggering number of drug overdoses is now higher than the number of deaths from motor vehicle accidents.

Additionally, a logical presumption would be that the rise in opioid prescriptions would correlate with a decline in chronic pain and even illnesses; however, this is not the case. The Center for Disease Control went on to state that there are noticeably “clear correlations between national trends for prescription opioid sales, admissions for substance abuse treatment, and deaths.”   According to a 2012 JAMA article, the specific amount of overdose deaths attributable to prescription opioids exceeds those attributable to cocaine and heroin combined. This rapidly-emerging and pervasive epidemic is gaining visibility, yet despite this increased awareness of the problem there is not much action being done towards beginning to solve it.

The lack of change and continual abuse of prescription opioids, is largely due to a higher demand from patients, particularly those with mental disorders and a history of substance abuse, to treat chronic pain that has fostered a powerful industry that grosses in billions of dollars each year. The increase in opioid overdoses correlates with the increase in opioid prescriptions, highlighting the leniency on the care provider level with prescribing opioid analgesics, a lack of regulation of patients prescribed to opioids, as well as proper education and warning being provided to these specific patients. Cross-prescribing and pill mills also play a vital role in the easy access to opioids and the increase in abuse. The number of overdoses due to opioids is especially high among individuals with mental diseases and those with a history of substance abuse, meaning that increased precautions must be taken when prescribing these individuals to opioids.

As stated by JAMA’s 2012 article, “Patients with mental health or substance use disorders are at increased risk for nonmedical use and overdose from prescription painkillers as well as being prescribed high doses of these drugs.” One of the primary causes of the heightened susceptibility is that the process is cyclical: chronic pain can cause depression, as well as a multitude of other mental health disorders, and depression and other mental health disorders can cause pain. This community is also exposed to a high vulnerability due to a lack of specialized regulation—which includes intricately keeping track of the medical and behavioral backgrounds of each patient and using that information when determining the dosage, level of precautionary information, and amount of follow-up visits—in the amount and level of opioids they are prescribed, frequent hospital visits with multiple doctors, multiple prescriptions, and a higher accessibility to prescriptions as a remedy for their disorders including depression, anxiety, and posttraumatic stress disorder. Also, because opioids suppress pain and can create a euphoric relaxed sensation, they can provide a release from stress which is particularly higher in individuals with mental health disorders or a history in substance abuse.

Action against this epidemic could include an increase in repercussions for mal-practicing physicians, the implementation of mandatory online databases across the nation to regulate what doctors are prescribing opioids to which patients, and an option for alternative pain treatments. With these implementations there will be less of an incentive to inappropriately prescribe opioids and, consequently, a decreased amount of unqualified patients who have access to prescription opioids. Social determinants are impactful, particularly for the population I described including the genetics they were born with, the families in which they were born into, as well as their conditions in which they live. However, even if they are unable to modify their situation, the regulation of patients on a care provider level can aid in decreasing opioid abuse and, in turn, the health of patients in spite of these outside influences.

Sources:

http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

httpp://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/oxycontin/Pages/opioids_dyk.aspx

http://www.ncbi.nlm.nih.gov/pubmed/24211157

http://www.ncbi.nlm.nih.gov/pubmed/21668754

Global Politics and Human Health

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A report recently published in The Lancet by a commission chaired by Professor Ole Petter Ottersen (of the University of Oslo) explores the implications that imbalances in power among various nations have for human health and efforts to move toward global health equity. This report illustrates the disastrous effect of political struggles on the quality of healthcare received by citizens of countries disadvantaged by such diplomatic setbacks. Professor Ottersen is quoted as asserting that the health inequities evident around the globe are “exacerbated by the current system of global governance that places wealth creation over human health.”

Vast technological advances in modern medicine have minimal repercussions for those who do not have access to basic healthcare. The report makes it clear that political intervention—or at least a level of cooperation among the health-minded and the politically minded—is necessary if progress is to be made. Current methods of international governance are deemed unsuited to the task for their lack of tangible, meaningful results in terms of improving the status of healthcare around the globe. Among the aspects of politics and world affairs that the commission considered to be influencers of the state of worldwide human health were food security, financial policies of austerity, and migration.

Calling My Children: Beyond the Photos

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Photo source

HIV/AIDS is a deadly disease that in the United States alone has killed over 600,000 people and still kills about 15,000 more each year [1].  In Nepal, a small country with a population of about 27 million (the equivalent of 4 New York Cities), has about 49,000 people currently living with HIV and 4,100 deaths due to AIDS in 2012 [2]. As of 2010, it is estimated that over 34 million people were living with HIV globally (though in 2012 the WHO estimates that it’s closer to 35.3 million), with 2.7 million new infections and 1.8 million deaths of AIDS-related illnesses [3].  Needless to say it is one of the most major and significant pandemics of our lifetime and is representative of many facets of international health disparities, as morbidity and mortality rates have often been correlated with social, economic, and even political factors (if WHO guidelines were met by 2015, over 4.2 new infections could be averted and 2 million lives saved [4]).  But, an interesting fact, no one has ever died from the actual HIV virus.  Most deaths from people living with HIV/AIDS are attributed to secondary infections, some even as innocuous as the common cold, that became lethal because of patients’ compromised immune systems.  So here’s the tricky part about AIDS: even though the virus living inside you is not what is going to kill you, it makes it so that practically any other pathogen might.  The life of someone with untreated or poorly treated AIDS consists of infection after infection after infection, with simple bugs that most people would not even notice making them bedridden and sometimes even on the brink of death.

David Binder, a nationally-acclaimed photographer, has followed this life for almost a decade, documenting the last year of life of a 27 year-old woman named Gail and the impact her death had on her family 10 years after her death.  These photographs later turned into a documentary called Calling My Children which, since its release in 2012, has been aired on national public television and screened in numerous  locations, including the United States Capitol.  Because of this work, AIDS advocacy is stronger than ever before and Gail’s family has been receiving support from ordinary citizens across the country.

To support David Binder’s continued efforts to document Gail’s legacy and advocate on the behalf of people living with HIV/AIDS everywhere, make a donation to the project here.

For more information or to explore David’s work, please refer to the website for Calling My Children and share Gail’s story so that her legacy can continue.

Gail Farrow’s story has profoundly resonated with diverse audiences through its presentation in magazines and exhibitions. This is a rare view of the bonds of family love that are both torn apart and endure through the ordeal of AIDS. The most powerful dramas are the ones where we can see ourselves and our loved ones. The story of Gail and her family gives us the opportunity for recognition and empathy.” [5]

Sources:

[1] http://www.cdc.gov/nchhstp/newsroom/docs/HIVFactSheets/TodaysEpidemic-508.pdf

[2] http://www.unaids.org/en/regionscountries/countries/nepal/

[3] http://www.worldaidscampaign.org/2011/11/unaids-world-aids-day-report-2011/

[4] http://whqlibdoc.who.int/hq/2011/WHO_HIV_11.03_eng.pdf

[5] http://www.callingmychildren.com/about/

The Unique Dangers of Child Marriage

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https://www.youtube.com/watch?v=jtUjqvXZzpY

Adolescent brides in Nepal are faced with the structurally violent nature of this culturally sanctioned practice. They must also contend, however, with the physical dangers of giving birth at an unhealthily young age–something that tends to go hand in hand with child marriage. This video and the issues it describes inform GlobeMed at Tufts’ commitment to improving maternal and neonatal care for the women and children of Nepal.