patients at a health center

Between interviews at a health center in Ngororoero District in Rwanda earlier this week, I sat quietly to take in the sounds of the health center. My whole life the sounds of hospitals have been sounds of the terribly sick — beeping monitors, hushed nurses trying not to disturb family members, quiet weeping, and moans of pain, frustration, exhaustion from patients. Granted, I haven’t spent much time in health care facilities in the US; I myself having the good fortune of seeing my doctor once a year for an annual physical. But the sounds of the health center in Ngororoero seemed to be conveying health and life, not illness and death.

In Rwanda, as is true across much of Africa, countries are shifting to a focus on primary health care and integrated service delivery. This is evident in the types of services that are provided at health centers, but also in the other activities taking place. Health centers not only serve as a place where mothers can bring their sick children, and the elderly can come to see the doctor or nurse; they are hubs for community health outreach activities, nutrition programming, and income generating activities.

As I listened to the hustle and bustle of the health center in the late morning, I heard the pained wails of babies being vaccinated against measles

a little boy with his child health card at the health center

and whooping cough. I heard excited chatter of mothers gossiping with one another as they waited to have their children weighed to ensure that they were growing healthily. A group of Community Health Workers had arrived to the health center to discuss the upcoming month of health promotion activities — including, promoting family planning uptake, particularly with men; encouraging members of their communities and villages to enroll in Rwanda’s mutuelle (national insurance program); as well as plans for the upcoming insecticide treated bednet distribution campaign, in order to protect against malaria in women and children. Beyond the enclosed structure I was sitting in, I heard tires urgently grinding on the gravel drive as the ambulance arrived at the health center with a pregnant woman who was experiencing complications during delivery. Hopefully she has reached the health center in time, and both she and her baby will survive.

Certainly the waiting area sees pregnant women with preeclampsia, who appear too tired to move, let alone talk. Elsewhere in the health center, women are delivering babies; certainly accompanied by the sounds of pain, joy, and the cry of newest additions to families. Elderly men and women at the health center to be treated for malaria, tuberculosis, and HIV. Their eyes are sharp, watching the children play in the courtyard. Young children whimper and cry as they quietly suffer from fever. Coughs signify acute respiratory infection, most likely pneumonia. Although this is the most quiet part of the health center, it is almost thunderous in meaning — they’re here for treatment, and they will be seen by a competent health care provider, and will likely leave today with the medications that they need.

As the day winds down, and sick patients are leaving with handfuls of medications and instructions for rest, water, and healthier meals, the noises that remain are the cogs of the health center humming. Papers rustle as notes are made in patient registers, final boxes are ticked in the vaccination section of children’s health cards, and nurses confer with one another quietly about today’s complicated cases.

As we pack up to leave, I think about all of the activities that have gone on here today — mothers left with supplies of fortified flour to cook for their children;  vaccinations given; malaria treated; antibiotics dispensed; and health promotion activities were planned. No doubt, this community is healthier today than it was yesterday.

a mother and her brand new baby boy

The HPV vaccine will help protect young women from the strains of the human papilloma virus that is the leading cause of cervical cancer.

When I travel, I look forward to learning from the drivers. So many questions pop into your mind as you drive through the city streets and rumble through the rural villages. In Malawi, I learned that the leaves hanging to dry alongside the homes were tobacco, one of Malaw’s largest cash crops. In Haiti, the drivers painted the picture of Port au Prince before the earthquake.  In Kigali, Abdoul explained to me that all of the motorbike taxi drivers are required to wear reflective vests and helmets. And the second helmet they carry, that’s for their passengers.

The other thing that I find helps open a new country to you is reading the newspaper. Fortunately, when I return to my hotel room at the end of the day, I find the Rwandan New Times waiting for me. The paper was established in 1995, shortly after the genocide, and is an English language paper published every day. Covering politics here in Kigali and around the world; as well as health, environment, education, other news stories, and of course sports.

In the past few days, I’ve read articles talking about President Paul Kagame’s twitter use; he’s one of the world’s leading political figures on Twitter, with more than 17,000 followers. Five baby gorillas were just named in a formal ceremony in the eastern part of Rwanda. The article went on to discuss environmental protection and protecting the gorilla habitat. Articles cover prosecution of perpetrators of the 1994 genocide, world refugee day, and the upcoming day of service for the whole country.

One of the most interesting articles I’ve read talked about Rwanda’s recent HPV vaccine campaign. This campaign has been trumpeted by Dr. Anges Binagwaho, Minister of Health, as a key intervention to protect women and girls from cervical cancer. HPV vaccination is new around the world, and has sparked heated debate in the US. The first campaign of HPV vaccination has reached almost 97% coverage, which is remarkable.

The campaign was targeting girls in school, aged 12-15 years. This is only the first shot, in a total of 3 that are required. The Ministry of Health, particularly the Maternal and Child Health Unit is encouraging girls to continue to follow up for the remaining two doses, which will begin July 19.  In addition to the vaccination campaign (which is being supported by Merck), the Ministry has ensured that this is a comprehensive cervical cancer program. A German organization (Qiagen) is providing cervical cancer screening tests, and the ministry is working to train health care professionals to screen women 35-45 for cervical cancer.

It’s hard to believe that a country that only 17 years ago suffered one of the greatest humanitarian disasters of my lifetime is now providing cervical cancer screening and HPV vaccination with such impressive coverage rates. It’s a testament to the commitment and leadership of the Rwandan government, as well as the Ministry of Health. I’ve asked my colleagues here to what they credit with the impressive gains, specifically in the health sector, and the response has been the same. It’s strong leadership across the board — from the President, to the Ministers, all the way down to the districts and the health centers. And it seems to be working. Rwanda is a living example of the improvements that can be made in a short time with strong leadership, health systems, political will, and deep seeded commitment to the health of a population.

Read the whole article here: http://www.newtimes.co.rw/index.php?issue=14662&article=42378

** This is VERY out of date; first round of the vaccination campaign ended in late June, and this article was highlighting the work of that first round of vaccination.

250 by 20 foot billboard along fenway park

This is a bit of a departure from the sorts of things I normally write about. I have had the good fortune to have my work take me around the world where I am focused on strengthening health systems and improving the lives of some of the most vulnerable populations — the very poor, disempowered women, and children — living in developing countries. However, the recent tragic events in my home town of Grand Rapids, Michigan have prompted me to think about gun control and gun violence in the US.

On Friday, July 8, an ex-convict went on a shooting spree, targeting two ex-girlfriends in Grand Rapids, Michigan. The gunman killed seven people, including the two women, members of their families, and the shooters own 12 year old daughter. In addition to the shooting spree, 3 people were held hostage, and at least one high speed chase ensued down the wrong side of a major freeway. Grand Rapids was in lockdown for the majority of the day, and the terror finally ended with the gunman’s suicide near midnight.

Now, before I get on my soap box, I want to clarify a few things. I grew up in a household with a gun. My dad hunts every fall, and without that gun, I wouldn’t be able to enjoy the venison that we freeze and my mom so wonderfully prepares each winter. I am not an advocate of removing all guns from all homes in the US, but I am an advocate of smart gun laws, improved gun safety, and an open and honest conversation about gun control.

In reading the reports coming out of Grand Rapids, news on the Huffington Post, and the most recent column by LZ Granderson, it has been suggested that alcohol and drug use played some role in the unfolding of the tragic events in Grand Rapids. It has also been suggested that some component of mental illness played a role as well.

I think that most people can get behind the fact that people should be subjected to a background check before purchasing a firearm. It’s possible that with background checks, coordination among states and government officials, and stricter gun control laws, many senseless deaths and injuries could be prevented. The tragic shooting that killed 6 people and wounded 19 others in Arizona at the hands of Jared Lee Loughener, armed with a large capacity ammunition magazine could have prevented if we agreed that civilians don’t need access to military style magazines designed to enable shooting mass numbers of people quickly and efficiently without reloading. (To urge your representatives to support the ban on deadly assault clips, click here: http://bit.ly/qeBCZh).

The massacre at Fort Hood (13 killed, 29 wounded) by a deeply disturbed Army Major in 2009 shocked the country. In 2007 Virginia Tech University suffered an unspeakable tragedy on their campus when 32 people were killed and 25 more wounded when the gunman, who had been diagnosed with severe anxiety disorder and was being treated for mental illness. Both of these cases bring out issues not only related to gun control and serious gaps in legislation, but also the perception and systems for treatment of mental health in the US. And, in 1999, Columbine, where 12 students and a teacher were killed, and 21 more injured in a high school.

Each of these places is supposedly a safe place — Grand Rapids Michigan, a mid-sized Midwestern city, a US Military Base, a university and a high school. My heart goes out to all those suffering in Grand Rpaids right now, and those that are still suffering in Colorado, Virginia, Texas, and Arizona; the aftermath of these traumatic events can last decades. In the aftermath of these shootings, communities are left asking themselves questions: Is Grand Rapids really a safe place to raise your kids? Can I send my child to school or college and not worry about their safety? Will I be able to better protect my family if I have a gun myself? I’m not convinced that if anyone in these settings had been armed more lives would have been saved. I think the thing that saves lives is improved gun control laws.

While I know it’s not real, the West Wing puts my thoughts into terrific words: http://bit.ly/qHX2M9.

If you’re looking for more information on gun violence in the US, check out the Brady Campaign (http://www.bradycampaign.org/). They have a fabulous website that provides good information on current legislation, accurate facts, and how you can take action. And, their most recent spokesperson: Plaxico Burress.

another older version of the same billboard

Women in Malawi waiting for family planning, reproductive health, and child health services. A great opportunity to capture cervical cancer.

Before Global Health Council this year, I was skeptical about spending too much time talking about non-communicable diseases; which to me meant cancer, diabetes, heart disease. It has been hard for me to wrap my head around the idea of establishing mechanisms to treat conditions that typically present themselves in adults if so many children are still dying of malaria, pneumonia, and diarrhea. If they don’t have access to clean water, insecticide treated nets, antibiotics, and a balanced diet, it seems inconsequential to be able to diagnose, treat, and manage a disease like diabetes or some kind of cancer if children continue to die of malaria before their 5^th birthday.

Over the course of the week, I learned a lot of things that I didn’t know about NCDs. First and foremost, what NCDs actually are. They go well beyond cancer, diabetes, and heart disease; including things like injuries, mental illness, HIV/AIDS, respiratory disease (which can be caused by various environmental hazards including tobacco smoke, solid fuel burning stoves, and other hazards like mining), stroke, cardiovascular disease, and cancer. I also learned that these conditions are not an affliction of only the wealthy — these diseases strike across all economic levels, regardless of if your country is industrialized or not, or has a functioning health system or not.

All of this was discussed in the opening plenary, but I still wasn’t convinced. I heard the Minister of Health and Social Welfare from Liberia, Walter Gwenigale, discussing the changes that Liberia is making to their basic health package, while not neglecting the challenges of malaria, pneumonia, diarrhea, and maternal death. His focus on planning and implementing key components that work for their population and within their health system resonated with me; if it fits, why not do it?

That though resonated with me all week, and led right to my ‘ah-ha’ moment about NCDs on Wednesday morning — I AM on board with them. I do think that they’re important, especially when they’re smoothly integrated into the already established health system. I attended a session on cervical cancer where methods of prevention were being applied in three low income countries: Mozambique, Peru, and India. In Peru, maternal mortality has dropped by 35% over some number of years, and in that same number of years, cervical cancer deaths have risen by 45%. A model of visual inspection with acetic acid (VIA) and cryotherapy has been applied with impressive results at detecting and treating abnormal pre-cancerous cells.

It was this session that opened my eyes to NCDs and the role that current implementers have to play in helping blaze the trail for NCDs. VIA and cryotherapy to detect and treat cervical cancer is quick and easy to implement at a wide scale; requiring nothing more than a few trainings, some vinegar solution, and some method of applying very cold temperatures to abnormal cells. A program like this could be easily integrated into current family planning and reproductive health programs, along with breast exams, and a simple discussion of risk factors. When solutions appear this simple, there are often complications that make them more challenging. But it’s important to push through the skepticism and work to identify strategies and programs that make sense for specific country context and situation.

With the many successful implementers of family planning, reproductive health, and STI programs around the world, we should have plenty of expertise to draw on in order to help identify how strategies can seamlessly integrate some of the cancer screening and treatment options into current programs. People will continue to identify ways to improve diagnostic abilities, identify funds, and strengthen supply chains which will all make diagnosis and treatment of NCDs more feasible in low- and middle-income countries, where so much of this disease burden is appearing. As Felicia Knaul from Harvard said in the opening plenary, ‘The opportunity to survive should not be defined by income. Treating NCDs is not unnecessary, impossible, unaffordable, or inappropriate.’

image is authors own

One of the most striking admissions I heard during the Women Deliver 2010 conference in Washington DC (June 7-9) was that the major challenge facing maternal health improvement is a lack of political will. Kathleen Sebelius, the US Secretary for Health and Human Services, suggested that the problem with improving maternal mortality lay not with the lack of knowledge or interventions, but the political will to put that knowledge to action, the will to make maternal mortality a priority of governments, the will to stand up and say that the lives of women matter, and we MUST do something about it.

I spent three days hearing people talking about proven interventions – improving human resources for health so that more clinics and facilities have trained birth attendants and midwives presiding over deliveries, expansion of in-service training to include Emergency Obstetric Care (EmOC) to more professionals and thus more clinics, wider distribution of clean delivery kits, immunization, kangaroo mother care, exclusive breast feeding, access to safe abortion, family planning, and antenatal care. The incredible people working in the field of maternal health know what to do, and how to do it. They do not have the power to demand the funds from their governments to make these interventions widespread. They do not have the power to make maternal mortality a national (or international) priority. They do not have the power to make their voices heard.

What I find to be the most striking about this, is the power that other, similar, causes have. LiveSTRONG is an amazing example. Lance Armstrong, and the rest of his team, have done a remarkable job of raising awareness, dollars, and determination to find a cure for cancer. TO FIND A CURE. There are a huge number of organizations and foundations to remarkable work to find a cure for cancer. Not that this work isn’t important, it is. But I find it mind-boggeling that so many resources are being poured into something that, right now, at this moment, we do not have the power to do anything about. Every day, nearly 1,500 women die giving life, and we know how to prevent almost 1,300, or 90%, of those deaths. The brains, the brute, and the determination is all there on the practitioner side, what we need is for our politicians to stand beside us, and let us do our work and save over one thousand womens lives, everyday.

All of this supports the awful reality is that women don’t matter; that our lives are somehow less valuable. However, after WD2010 and the Annual Global Health Council meeting last week, I cannot believe that to be true. In the run up to the MDG’s it’s more important now, than ever, to make the final push to achieve MDG-5. I hope that the world’s politician’s, starting with the G8 and G20 meetings next week, agree and finally put their political will behind the remarkable practitioners working tirelessly in less than ideal conditions, fighting to save mothers lives, everyday.

image from women deliver

The statistics are staggering. over 500,000 women die every year in childbirth. That is almost 1.500 women everyday. For every one of those women, it is estimated that anywhere from 15 to 30 other women suffer lifelong illness and disability. About 25% of these deaths are the result of hemorrhage or severe bleeding, another 15% from both infections and unsafe abortions, 12% eclampsia, and 8% from obstructed delivery. 99% of these conditions are preventable from simple interventions including clean birth kits, antenatal care, and delivery attendance by trained health care professionals.The global health community has the tools and interventions to prevent these deaths.

On Monday, June 7th, 2010, Washington, DC hosted the largest meeting on maternal health in over a decade. Women Deliver hosted an event of over 3,000 attendees from over 146 countries. UN Secretary General Ban-Ki Moon, Secretary of State Hillary Clinton, Secretary for Health and Human Services Kathleen Sebelius, Melinda Gates, Ashley Judd, and Christy Turlington each lended their voice to the cause of reducing maternal morbidity and mortality. Even more importantly, were the rest of the international public health professionals working tirelessly to save womens lives in their home countries, and around the world.

Over the course of the three days I was in Washington I attended sessions on womens empowerment, government engagement, human resources, health systems strengthening, emergency obstetric care, financing, and costing. I wasn’t able to attend sessions on the Pill, obstetric fistula, access to safe abortions, male engagement, HIV, family planning, and adolsecent health. The panel discussions engaged government officials, on the ground implementers, bilateral agencies, and NGO staffers to share their experiences, lessons learned, and ideas for the way forward.

Amazing individuals in the global health community shared their thoughts on “delivering solutions for women and girls” in moving and inspiring orations. Hillary Clinton has called on the global community, saying “women have delivered for the world, and now it is time for the world to deliver for women.” Anthony Lake, the director of UNICEF urges global health professionals to harness our outrage at the number of maternal deaths, and use that to continue our amazing work to solve this critical problem. Kathleen Sebelius, Secretary of Health and Human Services, accurately points out that global health professionals do not lack the knowledge, the interventions, or the manpower to reduce the number of maternal deaths, what we lack is the political will.

One of the most exciting moments of the conference was the pledge by Melinda Gates for an additional $1.5 billion in grants for maternal and child health interventions by the Bill and Melinda Gates Foundation. During her speech she said that one of the biggest challenges to improving maternal health is that we have to get people to accept that women and children are dying. I hope that in the coming weeks at Global Health Council, the G8 meeting, and the 2010 Summit on the MDGs, the global health community can increase awareness and support for maternal health, unify our voice, and move forward with renewed drive, determination, and purpose.

No woman should die giving life…

image from the bill and melinda gates foundation

image from edna adan hospital, somalia

May 12 is International Nurse’s Day. Nurses play a critical role in provision of care both at home and abroad. I find most of my care being provided by nurses when I go to the doctor – they take my history, ask about current issues and problems, do the basic health checks, height, weight, blood pressure, and then the doctor comes in for a brief consult and then I’m off. In some catchment areas, nurses are the only trained medical professionals around – so ALL of the care is provided by nurses. Nurses fill a critical gap in the provision of care around the world, and everywhere is feeling the shortage of qualified nurses to care for patients. But no where is feeling that shortage as drastically as the developing world.

The statistics are staggering. According to the most recent WHO bulletin for every 100,000 people Malawi only has 17 nurses. English speaking Caribbean countries have 1.25 nurses for every 1000 people, with an anticipated shortage of 10,000 nurses by 2025 – a huge problem considering these countries aging populations. In India, 2.4 million nurses will be needed by 2012 to achieve a ratio of 1 nurse for every 500 patients. What do these shortages mean? The countries with the biggest nursing shortages have the poorest health indicators – the populations of these countries aren’t being cared for, and the overall health of the population is suffering.

What are some of the causes of these nursing shortages? There are likely many – some examples include poor and inappropriate nurse training, there is poor career progression for nurses in many countries, poor health infrastructure and nurse migration. This migration occurs both at the national level (nurses leaving their developing country homes for better jobs in more developed countries) and also at a more local level (leaving rural areas where there is little opportunity, training, and support for positions in urban areas).

The issue of health care worker retention in rural areas is particularly interesting – all around the world, the individuals with the greatest need for health care often live in rural areas, and without access to trained health care professionals, rural areas often bear the greatest burden of disease. What this means, is that if we hope to make any progress at improving health around the world and achieving the Millennium Development Goals, we must ensure that those living in rural areas have access to the health care and trained providers.

So how can we fix this huge problem? By strengthening the health systems that nurses, doctors, laboratory clinicians, and public health professionals work in, we can hope to make their jobs and their opportunities more attractive. Financial incentives, accelerated promotional opportunities, and other non-financial incentives (improve housing, training opportunities, and additional educational experiences) have all been proven effective at drawing health care professionals to rural areas. If incentives are going to be used to improve the health care worker shortage in many countries, it is crucial that those incentives be based on performance, be well managed, and efficiently distributed. It makes no improvements to the health care workforce if incentives are given out without hinging on performance – it has the potential to be even more damaging to the health care system, and to the health status of individuals.

While these interventions certainly come with their own challenges (who will pay for it?, where will that money come from?, will inefficiencies be eliminated?), this is an important component of achieving the MDG’s. While progress is being made, there is much more work to be done, and improving the work force, strengthening the health systems, and ensuring that these interventions are efficient and achieving results are critical.

image from the Fred Hollows Foundation

Much of the information from this posting was drawn from the current issue of the Bulletin of the World Health Organization. You can find much more information on this topic here: http://www.who.int/bulletin/volumes/88/5/en/index.html

image from www.charitywater.org

Ironically enough, May 2 through 7 is National Drinking Water Week, encouraging American’s to drink tap water. Certainly Bostonian’s, and 2 million other Massachusetts residents will not be drinking their tap water early this week. A water pipe cracked in Weston and disrupted the clean water supply to 2 million Massachusetts residents.

While the response was swift, including ‘boil water warnings’ on TV, radio, and internet, national guard distribution of bottled water, and a rapid assessment of the dangers and an estimated time frame of repairs, I couldn’t help but feel that the public response was a little bit of an overreaction. Stores were wiped clear of bottled water, and anxiety and emotions were running high at distribution points, grocery stores, convenience stores, coffee shops, and restaurants. Shoppers at my local grocery store were frantically filling carts with bottled water, gatorade, soda, juice, and any other drinkable substance they could get their hands on. Corporations in the area spent a fair bit of time determining how they would supply their employees with coffee Monday morning. And I am sure that there was more than one tirade at Starbucks and Dunkin Donuts on Sunday morning as people tried to get their hands on a Sunday morning latte.

While surely an inconvenience, crystal clear water is still flowing from my tap. And it’s heated. The stove in my kitchen is clean burning, and not emitting smoke and other fumes making me and my family sick. And the water can be transferred to any number of clean containers with lids, and put in the fridge immediately to cool.

Bostonian’s are not walking miles for water and then carrying 40 pound jerry cans on their backs to get the water home. We aren’t boiling water over open fires. And our water isn’t clouded and muddy with visible contaminants. And, if we don’t to boil water, we can hop in to our cars and drive to the grocery store where we can pick up cases of Poland Spring Water. Well, a limit of 2.

I hope that this water crisis in Massachusetts sheds some light on the REAL water crisis going on around the globe.

Worldwide, almost 1 billion people (one in eight) lack access to clean safe drinking water. This lack of clean water takes an unbelievable toll on the population in the developing world. Each week, 42,000 people die from unsafe drinking water. 90% of those deaths occur in children under 5. Not only does poor drinking water cause a myriad of illnesses (including dysentery, cholera, and other diarrheal diseases), but it also inhibits gender equality, access to education, and a growing food supply.

Women often collect the water, meaning they spend hours walking to and from (often unprotected) water sources. This often prevents girls from attending school and furthering their education and also puts women in danger of attack and sexual violence, especially in conflict ridden areas. One can see the opportunities for women to improve the lives of them and their families, as well as improve the communities they live in.

Providing access to clean water not only prevents illness, death, and other challenges, it can also improve the food supply and strengthen the economy of a community. By ensuring that there is a near by water source, not only is there water for drinking, but also for irrigation and use in agricultural activities.

There are many places where you can go to make a donation to help improve the water crisis around the world. One of my favorite charities is charity: water. 100% of public donations go directly to one of their 2,524 projects in schools, health clinics and hospitals, and communities.

www.charitywater.org

image from http://www.dcp2.org/features/58/givers-of-life-condemned-to-death

Yesterday the New York Times published an article under the headline, Maternal Deaths Decline Sharply Across the Globe. With the final push to the Millennium Development Goals, all eyes are on the achievements and progress that organizations have been able to make since 1990 in reducing poverty, improving education, and making people healthier. MDG-5 – reducing maternal mortality by 75% by 2015 – got a big boost in press yesterday thanks to a Lancet article published this week. Not only was the Lancet article covered by major news outlets like the NY Times, AP, Reuters, and NPR, reporting the successes of organizations in reducing the number of women who die in during pregnancy, in childbirth, or in the 42 days following the termination of a pregnancy, but there was also a debate between international health and development professionals about the release of the information.

Christopher Murray and his colleagues received funding from the Bill and Melinda Gates to undertake one of the most extensive and accurate studies of maternal mortality in 181 countries. The methods were remarkable; using accurate modeling methods, extensive data sources, and robust data analysis. This is the first study of this magnitude to be produced, and it has encouraging results.

In 1980 there were an estimated 526,300 maternal deaths. In 2008 that number was down to an estimated 342,900. This is an unprecedented 35% drop in maternal mortality in 28 years. Another number to think about is the Maternal Mortality Rate, which is the number of deaths per 100,000 live births. In 1980, the MMR was 422, reduced to 320 in 1990, and in 2008 to 250. This is a yearly decline during the life of the MDGs (1990-2008) of 1.3%. There are a number of reasons why maternal health is improving. Certainly some of the improvement can be due to political backing from the US, including Obama’s Global Health Initiative and the White Ribbon Alliance for Safe Motherhood. Other reasons for the improvement include higher household income, increased maternal education, a lower total fertility rate (the number of pregnancies a woman experiences in her lifetime), and an increase in skilled birth attendance.

While these improvements are remarkable, our work is far from over. 50% of all maternal deaths occur in six countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia, and Democratic Republic of the Congo. HIV rapidly becoming one of the biggest problems for maternal health providers. Without HIV, the improvements to maternal mortality would be much greater and impressive – a MMR of 206. The fact that the MMR is dropping by 1.3% every year is definitely something to celebrate, but it’s not enough to help us achieve the MDGs. In order to reduce maternal mortality by 75% by 2015, the MMR has to drop by 5.5% annually. And while 342,900 may seem like a great improvement, 939 women are still dying everyday from pregnancy related causes.

So what’s next? One of the most crucial pieces of information is missing from this discussion – what is having this great impact? This article, while encouraging, tells us that we’re doing something right, but we don’t know what that is. There are countless interventions targeting maternal mortality around the world. The NY Times article highlights Conditional Cash Transfers (paying women to deliver in clinics), home visits by health care workers, provision of EmOC (Emergency Obstetric Care), and scale ups of primary health care. But we still don’t know which of these works best. A comment published alongside the article in the Lancet highlights some key points here: integration of services, political and advocacy power, and the need for continued robust data collection and analysis.

One of the most interesting debates and discussions surrounding the Lancet article was not about the facts and figures, but whether or not the study should have been released right now. NPR published a story about the article and the swirling debate among public health professionals. There is valid fear that the publication of these results will detract attention, and more importantly funding, from a cause that is far from won. Advocates went so far as to pressure the Lancet into not publishing their findings until September.

This is a fascinating debate – will the release of this information do more harm than good? I certainly hope not. It’s important that international public health professionals broadcast our successes. Without publishing robust results like these, how can we continue to convince people that we are doing good work, work worthy of their donations and support? I believe that we can’t. However, it’s also important that the message not be misconstrued. While progress has clearly been made, 939 women dying each day as a direct results of pregnancy is too high a number, and much more work waits to be done. And we owe it to the women of India, Pakistan, Afghanistan, Ethiopia, Democratic Republic of the Congo and Nigeria to continue to work on their behalf, ensuring that they have the right to a  safe and health pregnancy.

“Women have long delivered for society, and, slowly, society is at last delivering for women.” Are we? Lets make sure we continue to…

For more information on Maternal Mortality, check out http://maternalmortalitydaily.wordpress.com. It’s a great blog continuously updating the challenges and successes to achieving MDG-5 from around the globe.

Photo from Partners In Health (www.pih.org) website.

Everyday inches the survivors of Haiti’s earthquake closer to hurricane season, which begins on June 1. Twitter has been full of tweets reminding us that the hurricane season is rapidly approaching and that Haitians are not ready for heavy rains. The risk for disease and destruction is already staggering, and will only increase with the impending rain. While the conditions are daunting, relief organizations and Haitians are up to the challenge.

Two weeks ago, the United Nations and the US Government, alongside the Haitian Government held a Donor’s Conference with the objective being securing funding to rebuild Haiti. According to Anderson Cooper, the goal of the conference is to secure close to $4 billion which is the start of a 10 year, $10 billion plan to rebuild Haiti. I find it so admirable that Haitians, and those working on their behalf, refuse to let their future be written for them.

Of all of the plans to rebuild Haiti that are being circulated right now, I think the most remarkable one is the urban development plan that addresses a number of Haiti’s biggest challenges: congestion in Port au Prince, lack of economic opportunity outside of the major city, and poor housing codes. The confluence of all of those factors are in part what contributed to such an unimaginable death toll in the earthquake.

The New York Times has a piece on this remarkable plan, highlighting the need to redistribute the population to places outside of Port au Prince that are less vulnerable to disaster. This begins with reopening ports in the northern part of the country; ports that were closed after the American take over in 1915. In the wake of the disaster, people have been fleeing the congested capital, and planners see this as an opportunity to follow the fleeing population with services and jobs – including schools, hospitals, clinics, markets, and soccer fields. By providing these services in the rural areas, it will encourage people to remain out of the capital and rebuild a life that was possibly better than the one they had before.

Included in these plans are both urban and rural plans, housing options, and building and zoning codes. It is worth pointing out that plans like this erupted in the wake of Hurricane Katrina. However, the guidelines and progress of the planning is beyond anything that has been prepared for New Orleans or Southeast Asia after the tsunami in 2004.

These are brilliant and exciting plans, and demonstrate resilience, determination and pride. All qualities that lead me to believe that Haiti might just be able to not only survive, but to thrive.

photo credit: Damon Winter/The New York Times