Global Health Blog

  1. Community Health Administration Associations: Community health empowerment for Peruvians

    July 28, 2014 by Kathleen Ferraro
    San Jeronmino CLAS center

    San Jeronmino CLAS center

    I am currently researching the community health worker model in Peru, a project which has necessitated extensive background research on Peruvian health care and the community health worker model’s past, present, and potential in the country. This background research included information on the Community Health Administration Associations (CLAS) program, a program that diverges from the conventional community health worker model but provides community-based primary care nonetheless.

    As a background, the community health worker model is a primary care model wherein local community members are trained to administer basic health services to other members of their community. This model is steadily gaining popularity worldwide, often commended for its potential for community empowerment and accessibility. In Peru, studies of the community health worker programs in place acknowledge the efficacy of the model on paper, but criticize the fact that the bulk of Peruvian community health workers are males with little to no education that exhibit high dropout rates from their community health work (Brown et. al. 2006).

    However, the CLAS program, implemented in 1994, is proving to heighten the potential of efficacious community health work. The WHO defines the CLAS program as a system of “private, non-profit civil associations [(legal non-profits)] that enter into agreements with the government and receive public funds to administer primary health-care (PHC) services applying private sector law for contracting and purchasing” (CITE). These individual community CLAS associations effectively identify local social determinants of health and health inequities, and then reinvest their Ministry of Health-supervised budget in community outreach programs and infrastructure development.

    As it relates to the community health worker model, the CLAS program is essentially a government health initiative with authorized and integral community participation. Health personnel working at CLAS associations are formally hired by CLAS and are held accountable by the community members their center works with, thereby necessitating transparency and communication with service recipients. In that way, community members influence the health services offered, and CLAS associations respond to the needs and health disparities specific to their localities.

    All in all, the CLAS model has proven to have favorable impacts on health, health services development, and community outreach. CLAS association clinics boast significantly higher numbers of staffing physicians in comparison to non-CLAS clinics (and therefore shorter waiting times and more personalized treatment) with a higher average of annual clinic visits among their target populations. The centers also exhibit higher access and more customized primary care, especially for poorer rural populations that tend to be dissuaded by unaffordable fees. They do so by focusing on what the individual community needs and responding to only the relevant inequities and necessary services–in short, affording accessibility by efficient service development and implementation.

    Government and organizational initiatives continue to develop in the hopes of further strengthening the CLAS program by monitoring impact, fostering community-based education, broadening the reach of CLAS centers, and increasing CLAS partnerships with schools, organizations, and other relevant institutions.

    With initiatives like this in place to strengthen a program that already demonstrates significant impact, it is exciting to see where this community-based primary health care system goes in the future. Likewise, it will be interesting to see how non-CLAS community health worker programs interact with, borrow from, and impact the CLAS model to continue to expand the reach of community-based health care in Peru.

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  2. Questioning Domestic Violence

    July 25, 2014 by Haley Lillehei

    According to the National Coalition Against Domestic Violence (NCADV), one in every four women will experience domestic violence in her lifetime. This violence is not confined to any one group – it is an epidemic that is affecting individuals from every background, regardless of age, economic status, race, religion, nationality, or educational background. The consequences of domestic violence seep into many areas of life and can have remarkable effects beyond the immediate act.

    The NCADV released a domestic violence facts sheet in 2011 that gives a brief discussion of the issue within the United States. 85% of victims of domestic violence are women, and most of these females are victimized by someone they know. Most cases of domestic violence are never reported to the police and can have lasting repercussions – intimate partner violence is a substantial public health problem in the US. Last year (2013), the House renewed the Violence Against Women Act, which is legislation to offer protection to victims of domestic abuse. In response to the passing of the act, Obama said “Renewing this bill is an important step towards making sure no one in America is forced to live in fear.” This is a measure towards addressing the issue, but intimate partner violence is still a large problem that needs to be confronted to a greater extent.

    The challenge thus remains how to most successfully prevent domestic violence. One of the greatest challenges to overcome is the patriarchal norms in the society we live in. Domestic violence, although most often perpetrated by individual men and boys, is a product of a larger system. Jackson Katz, a gender violence prevention educator, has an interesting perspective on the issue of domestic violence.  In a TedTalk titled “Violence Against Women – It’s a Men’s Issue” Katz explains how the problem of domestic violence is usually categorized as a woman’s issue, but, he says, it is time for a change.

    “They’ve been seen as women’s issues that some good men help out with, but I have a problem with that frame and I can’t accept it. I don’t see these as women’s issues that some good men help out with. In fact, I’m going to argue that these are men’s issues, first and foremost. Now obviously, they’re also women’s issues, so I appreciate that, but calling gender violence a women’s issue is part of the problem for a number of reasons” (Katz, 2012).

    Katz goes on to describe all the problems with calling gender-based violence a “women’s issue” – some men hear that term and tune out.

    Jackson Katz

    Jackson Katz

    Katz uses a linguistic model to illustrate his point. The phrase “John beat Mary” changes, through a few steps, into the phrase “Mary is a battered women.” John has entirely left the conversation, and the violence that was perpetrated against Mary has become her identity. “Mary is a battered woman,” Katz points out that our whole cognitive structure is set up to ask questions about victims. What did Mary do that made John upset? Did Mary forget a responsibility? The questions continue, and they are all focused on Mary. Instead of asking questions about Mary, we need to start asking a new set of questions. “What is going on with men? And then what is the role of the various institutions in our society that are helping to produce abusive men at pandemic rates?” (Katz, 2012). The questions need to shift to focus on the causes of violence, as that is how we will truly figure out how to prevent it.

    Domestic violence is a deeply rooted and systematic social problem. Katz wants to know “how can we change the practices? How can we change the socialization of boys and the definitions of manhood that lead to these current outcomes?” (2012). These questions are hard, because they rock the boat and challenge the status quo, but they are the only way to make a real change. They will be resisted, but the more people that can join the conversation and ask the questions, the more momentum gained.

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  3. The Pebbles Project: A Reflection

    July 21, 2014 by Emily Drewry

    Emily Drewry participated in the Northwestern Public Health and Development in South Africa study abroad program in Spring 2014. As part of her studies, she spent six sessions working with a local NGO to integrate her understanding of South African health systems with understanding of community development.

    IMG_3026The Pebbles Project is a nonprofit organization whose offices are located on the Villiera Wine Farm in Somerset West, South Africa. Founded in 2004, the organization’s initial goal was to help the children of wine farm workers, many of whom are affected by alcohol abuse early on and throughout life. Children living in the Winelands communities have been identified as high risk for significant instances of Fetal Alcohol Syndrome and developmental delays due to increased exposure to pesticides from living on and near wine farms. Through working with this organization, we were able to integrate our budding understanding of South African health determinants. We were able to spend time with the nurse practitioner, an incredibly knowledgeable woman, as well as  one of the early childhood program teacher at Pebbles during our time there. Ending with a cumulative project about what we’d learned, the time at Pebbles left a lasting impression.

    The day we first drove up to Pebbles, the natural beauty of the Winelands around the office stunned us. We were so excited to meet the staff, tour the location, and get started with our work. It became clear that we would be working on a few projects while at Pebbles, but that our time there would be largely based on their needs on a week-by-week basis. We toured the facilities that first day and were excited to see a new clinic where families of wine farm workers could come to receive care. Because it just opened, the clinic wasn’t receiving many patients, but there’s no doubt that it will be an integral part of the Winelands community in the future.

    IMG_3037The Public Health and Development program focused on a different determinant of health each week, effectively introducing us to the status of South Africa within the realm of health, and creating comprehensive background for us to apply to our time at Pebbles. For example, the week of occupational health especially stood out to me as important progress in my understanding of South African health determinants. I was already familiar with the workings of Pebbles by that point in our time here, but I had never contemplated the occupational hazards present on the wine farms. After a week of coursework related to occupational health, I returned to Villiera with a broader understanding of concerns for employees and the required actions to remain in good health while working in jobs that require manual labor. Things I had never considered before, such as repetitive strain injuries due to long days of repeating motions, became illuminated and further highlighted the need for a clinic on site.

    As part of our work at Pebbles, we were tasked with creating a hygiene project for the young children of the crèches. After observing for a day, we noted that the biggest gap in hygiene came in the process of washing hands. Not only did the children fail to wash their hands at home, according to the teacher, but also when asked to do so at the crèche, they simply dunked their hands in water and considered it done. We worked on creating a presentation that would be understandable by 3-5 year olds that showed them why they wash their hands and how to do so effectively. Using a basic explanation of a germ and demonstrating how long to wash our hands to the tune of Happy Birthday, we presented on our final day at Pebbles and were thrilled with the responses we got from the kids. They sang along with us as we let them practice afterward, and we left the materials behind for the teacher to replicate the presentation in the future. For children so young, it is difficult to explain concepts as difficult as germs, but we hoped to have made a lasting impression on their habits that will greatly affect their health down the road.

    I could not have been happier with the placement at Pebbles; the wine farms were, to me, a fascinating community to learn about for the past ten weeks. Not only was it a group I had previously little knowledge about, I found the determinants were apparent within the community, but also being addressed by Pebbles. The organization offered a comprehensive look into the challenges of a specific community, and I appreciated the chance to identify each program and how the goals matched the health needs of the community. Pebbles offers a variety of programs, from early childhood development centers, to afterschool clubs, to parents workshops about finances, personal development, and positive parenting. The various parent programs, for example, worked well at addressing the psychosocial and occupational health problems seen among adults in the wine farm communities. The development of individuals within the Winelands communities will be forever improved because of Pebbles’ comprehensive goals and programs.

    I left South Africa with a broader interest in health – not only will I continue to seek out opportunities in nonprofits abroad, but I will bring to the table the skills it will take to join and learn about a new community, especially one I’d never considered before. Pebbles is one of those organizations that will stick with me for a long time, not only because of the opportunities we had to become a part of their team, but because of the complex task they have undertaken so positively.

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  4. Apna Ghar: Empowering Asian American Victims of Domestic Violence

    July 15, 2014 by Haley Lillehei

    Last quarter I took a class on Asian American women and different issues they face in the United States. One assignment was to look up an organization in the Chicago area serving these women. I chose Apna Ghar, an organization in Uptown Chicago, which tries to fill the gaps in domestic violence relief services in the Asian American community. After this project, I decided to reach out to Radhika Sharma, Community Health and Violence Prevention Specialist at Apna Ghar, to learn more.

    Apna Ghar first opened its door in 1989 with the goal to “provide comprehensive multi-lingual, multi-cultural services, including shelter, for South Asian immigrant women seeking lives free from violence.” Since it’s founding, Apna Ghar has worked to offer assistance to all women, regardless of their racial background, and provides a wide range of services that focus on South Asian immigrant women. Its founder recognized that Chicago shelters did not know how to deal with the issues specific to South Asian women. Their experiences were not the same as in white middle and upper income families, who are often the targets of domestic violence shelter’s services. There was also a need for legal assistance for immigrant women who are undocumented or whose residency in the US is dependent on their abusive spouses.

    Radhika Sharma notes that while gender inequities exist in almost all cultures,

    “the hundreds of distinct cultures within the Asian American category include the focus on the individual as part of a larger family unit. This means that some Asian American Domestic Violence victims refrain from speaking out about their abuse for fear of bringing shame to the family. It also means that the abuse might be perpetrated not just by the spouse but by the spouse’s family” (2014).

    The emphasis on family and traditional values can make the situation especially hard for immigrant women.

    To address all of the barriers Asian American women face while attempting to find relief from domestic violence, including cultural and linguistic ones, Apna Ghar aims to be a culturally specific space. This helps the abused women, who, according to Sharmila Rudrappa, often feel “a strong sense of wanting to be in a familiar cultural space where they could reconstitute their lives in ways that were culturally comprehensible and within their control.” Asian American survivors of domestic violence needed a space where they felt comfortable, and not like outsiders as they are receiving care and assistance. Apna Ghar provides a space with more flexible policies – one in which women can cook their own food and speak with the multilingual staff.

    Most importantly, Apna Ghar focuses on helping domestic violence survivors become self-sufficient and empowered. It offers a wide-range of services to accomplish this goal, including education, transitional housing, counseling, and legal services. For example, the organization provides a 24-hour hotline which addresses immediate safety concerns and provides referrals and information to callers. It also provides an emergency shelter with 15 beds, transitional housing for 18 to 24 months for those who are working to rebuild their lives, counseling to help women and children work through trauma associated with abuse, and legal advocacy geared towards helping both residential and non-residential clients through the United States legal system. Likewise, Apna Ghar has a Supervised Child Visitation and Safe Exchange Center, in which children are able to interact with a non-custodial parent under supervision.

    Apna Ghar’s website includes a section that discusses “success” stories of women who have utilized their services to escape abusive home situation and rebuild their lives. There are stories of women, like Maria, who was tricked into coming to the United States and becoming a sex slave, and Vijaya, who came to Apna Ghar to escape violence in her home while she was pregnant (names changed to protect confidentiality). The stories are touching and powerful, and show the good work Apna Ghar is doing within the community. To find out more about Apna Ghar or become involved, see their website at http://www.apnaghar.org/.

     

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  5. The Growing Crisis in Guatemala: Why Coffee Rust is a Pressing Public Health Issue

    July 1, 2014 by Elizabeth Larsen

    Agriculture Landscape (1 of 1)
    You may have noticed this week that your usual Starbucks coffee costs a bit more than usual (1). This slight price increase is, in part, a consequence of Roya, a fungal plant disease that is attacking coffee plantations around Guatemala and the rest of Central America. What you may not have known is that Roya is not only decimating coffee crops, but it is also having profound effects on the health of thousands of Guatemalans.

    Guatemala’s history with coffee is long and complex. It begins around the 19th century when Spaniards began stealing large plots of land from indigenous Mayan communities, converting them into plantations, and forcing the indigenous populations to work for them. Through colonial trade and tax laws, the Spaniards restructured Guatemala’s agricultural economy to be heavily dependent on coffee. In this way, coffee became the principal export of Guatemala, reaching 90% of the countries’ exports before 1900 (2).

    Throughout the 20th century land reforms and civil war in Guatemala, the coffee industry exacerbated the narrative of poverty, racism, and inequality among indigenous populations that had begun centuries earlier. Today, coffee production throughout the country continues to be marked by rich coffee finca owners using indentured servants and migratory farm workers to harvest their beans. As coffee remains Guatemala’s largest export to this day, there are thousands throughout the country that depend on the crop for their livelihood.

    The importance of coffee exports in the country is precisely the reason that Roya has been so detrimental to the health of Guatemalans. Roya is an airborne, fungal disease, sometimes referred to as coffee rust. It spreads quickly in humid environments, causing coffee leaves to become speckled with rust colored spots, before drying up and falling off. The only potential cure for the harmful fungus is multiple applications of expensive fungicides that are often ineffective.

    Since the 1970s, Roya has been a problem in the warm and wet Central American countries, such as Costa Rica and Nicaragua, but has left the cooler, mountainous Guatemalan coffee farms alone (3). However, in recent years, the region has experienced the effects of widespread climate change. The fungus began afflicting Guatemalan farms around 2012 and was recently declared a national emergency by the Guatemalan government (4). The fungus is estimated to have caused over $1 billion in damages since 2012 (5). It is now estimated that 70-80% of coffee crops are affected by the disease. This is among the highest rates out of any Central American country.

    Roya is affecting everyone involved in the coffee distribution chain — from Starbucks consumers to the rich coffee finca owners to the poor farmers working in the fields. Coffee harvests of Guatemalan plantations have plummeted to 1/20th of what they used to be (3). The only solution is to trim back the foliage of old plants in hopes that they will sprout new, healthy leaves. Even with this strategy, the plants will not produce the valuable coffee beans for two to three years. Because of this, many farmers have taken to planting new trees that are more resistant to the fungus, but will take years to become productive.

    The consequences of this plight of coffee rust reach far beyond increased Starbucks prices. Throughout the many coffee growing regions of Guatemala, including Sacatepéquez, Sololá, Quezaltenango, San Marcos, and Alta Verapaz, hundreds of thousands of people are now without work. Coffee planters and pickers have tried to switch to new crops such as plantains and bananas, but the value of these commodities is far less than that of coffee. Because a large portion of Guatemala’s population struggles with food security, this substantial amount of job loss from the economy will have widespread health effects.

    Employees of organizations that work with the indigenous poor around the highlands, such as Mayan Families, state that they’ve seen in increase in families struggling to feed their children. Given that the first two years of a child’s life are crucial for their long term development, one hard season can have devastating consequences on child growth, leading to impaired mental and physical development. In a country where 49.8% of children suffer from stunted growth already, the coffee fungus has the potential to undo much of the nutritional progress that has been made over the last decade.

    So far, the response to the epidemic has been varied. Since April, the World Food Program has been providing emergency food assistance to 14,000 families across Guatemala (6). While admirable, this is a small portion of the hundred of thousands Guatemalan families that are suffering from the outbreak.

    Then, just  two days ago, The U.S. Agency for International Development (USAID) launched a $23 million dollar fund in partnership with Keurig Green Mountain, Cooperative Coffees, Starbucks, and Root Capital to support the thousands of coffee farmers affected by the devastating fungus (3). The fund will be used to “provide on-farm, agronomic trainings on climate-smart, resilient practices to coffee farmers and farmer organizations” and to rehabilitate ”disease-affected fields and… stabilize coffee supply chains in Latin America and the Caribbean (3).” Though this support is crucial for the coffee industry, these solutions will take years to return farms to full productivity and do little to alleviate the immediate suffering of families.

    Clearly, the effects of the Roya fungus have rippled throughout the country of Guatemala. No one solution will mitigate the repercussions of this epidemic plant disease, but multifarious efforts that address both household income and food security, as well as large scale agricultural and economic factors will continue to make progress towards overcoming it. Though the challenges are great, in the words of longtime Guatemala resident and coffee shop owner, Michael Roberts, “Guatemala has been through a lot. What’s gotten them through is the resilience of the people.”

    (1) Wagner, Meg. “Starbucks Hikes Prices on Brewed Coffee, Lattes, Bagged Beans.” NY Daily News. N.p., 24 June 2014. Web. 27 June 2014.

    (2) “The Culture of Coffee in Guatemala.” Coverco – Commission for the Verification of Codes of Conduct. N.p., n.d. Web. 27 June 2014.

    (3) ”Devastating ‘coffee Rust’ Fungus Raises Prices on High-end Blends.”OregonLive.com. N.p., 31 May 2014. Web. 27 June 2014.

    (4) Davidson, Kavitha A. “Guatemala Declares National Coffee Emergency.” The Huffington Post. N.p., 09 Feb. 2013. Web. 27 June 2014.

    (5)  ”USAID, Texas A&M Invierten $5 Millones Para Combatir La Crisis Causada Por La Roya Del Cafe.” U.S. Agency for International Development. N.p., 19 May 2014. Web. 27 June 2014.

    (6) ”Guatemala: WFP Assists 16,000 Families Affected by Coffee Rust and Drought.”World Food Programme. N.p., 30 May 2014. Web. 27 June 2014.

    (7) ”USAID, Keurig Green Mountain, Cooperative Coffees, Starbucks and Root Capital Launch $23 Million Resilience Fund to Help Farms Fighting Coffee Rust Crisis.” U.S. Agency for International Development. N.p., 19 June 2014. Web. 27 June 2014.

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