Persevering in Central African Republic
One morning this week, an aid worker saw scores of Muslim refugees climb into 30 trucks in a town in the southwestern corner of the Central African Republic. Fleeing violence, they were headed to the border with Cameroon. Many ultimately want to get to ancestral homes in neighboring Chad, even though their families have lived in the Central African Republic for generations. This evacuation was just one episode in an unfolding humanitarian crisis characterized by fighting between Muslims and Christians in recent months. Nearly one million people, roughly one-fifth of the population, have left their homes. Refugees now huddle in sprawling settlement camps in the capital, Bangui. One camp, by the airport, already has more than 100,000 people. Interim President Michel Djotodia left the country, and this week lawmakers chose Catherine Samba-Panza, the Mayor of Bangui, as the next interim President, the first woman to serve in this role.
Social and political upheaval always poses an extra challenge for health programs. But the diseases do not follow political developments. A relatively weak health system in Central African Republic has been further strained by the humanitarian crisis, with the mass dislocation and with the ransacking of health facilities in some areas. Yet the Global Fund is continuing to work hard with partners to fight a serious malaria epidemic, and continuing efforts on HIV and tuberculosis. “We are determined to keep fully engaged in the Central African Republic with our partners at a time when violent upheaval is putting many vulnerable people at increased risk,” said Lelio Marmora, Head of the Africa and the Middle East Department at the Global Fund. The Central African Republic faces many health challenges, with estimates that 16 percent of children die before the age of five. Malaria is a big killer. The Global Fund is currently working on a project with the International Federation of Red Cross and Red Crescent Societies (IFRC) to enable distribution of more than 2.3 million mosquito nets. The Global Fund is also part of efforts to keep testing and antiretroviral therapy for HIV on track, and keep supplies of anti-TB drugs coming. Before the country’s descent into chaos, more than 16,000 people were receiving antiretroviral treatment with the support of the Global Fund. “We are able to deliver drugs to the central warehouse at Bangui airport, but we are struggling to get HIV and TB treatment to the health facilities,” said Corina Maxim, a Program Officer at the Global Fund. “We don’t know what is getting through because of the disruption and all the people who have hidden in the bush.” The efforts will continue.
(photo by hdptcar / Flickr)
Why Stigma Matters
Stigma appears in some form in every country of the world, but it always seems to affect those who are most vulnerable in a society. When a country passes a new law or endorses a practice that criminalizes men who have sex with men, or sex workers, or migrants or other groups, they engender stigma or discrimination or even threats of violence that can drive the most vulnerable further underground. Yet consistent experience proves that these people are among the most vulnerable to HIV, TB and malaria. Anything that further marginalizes them generally guarantees that these diseases will thrive. Criminalizing men who have sex with men hinders access to HIV services, and can seriously undermine a national program to defeat the disease.
Laurindo Garcia, an activist and campaigner on issues related to HIV, sexual orientation and human rights who works and lives in the Philippines, has a good story about stigma and how to overcome it. When Laurindo told his family he was HIV positive, his father’s first reaction was one of shock and pain. In the Philippines, as in many parts of the world, having HIV is highly stigmatized, so families tend to be silent about it. After a long process of talking to his family and to his partner, Laurindo decided to come out publicly about his HIV status in order to combat fear and discrimination. Today, the 40-year old gives speeches and does one-to-one counselling through the internet and mobile phones, and his father, Albert, is among his greatest supporters. “The battle over stigma will not be won in parliamentary halls or courtrooms,” Laurindo writes in his latest blog. “It will be won in people’s homes, bedrooms, classrooms; at business lunches, family reunions and even at beach parties.”
The Global Fund is committed to protecting and promoting human rights and to removing human rights barriers to health services for all populations. Experience all over the world – in the Americas, in Europe, in Africa, in Asia – shows that stigma matters because it undercuts the evidence-informed, rights-based response needed to overcome HIV. So how can we challenge stigma? Visibility, writes Laurindo. By encouraging others to talk openly about key affected populations, gender equality, and human rights. It is the same potent weapon that has transformed many social justice agendas through history, from the women’s movement to civil rights and racial discrimination, Laurindo notes. “Nothing will change unless more individuals choose to step into the spotlight, making their voices heard so others can understand that regardless of HIV status, race, religion or the expression of one’s gender we are all flesh and blood, and we all have the right to happiness.”
Joining Forces in the Mekong
The great progress made against malaria over the past decade has raised hopes that the global community can defeat the millennia-old disease and remove it as a threat to global health. But a wily parasite resistant to artemisinin in a handful of countries in Southeast Asia is threatening to undermine global progress. Parasite resistance to artemisinin - the core compound in the world’s most effective antimalarial medicines - has been detected in Cambodia, Myanmar, Thailand and Viet Nam. While the cases represent a small portion of malaria cases worldwide, health experts are warning the geographic scope of the problem could widen quickly, posing a major health security risk for many countries in the region and beyond with ongoing malaria transmission.
In December 2013, the Global Fund’s Board approved a US$100 million grant over the next three years to tackle the emergence of artemisinin-resistance in Thailand, Vietnam, Myanmar, Laos and Cambodia. The Regional Artemisinin Resistance Initiative, or RAI, is the result of a collaborative effort between multiple partners and the Ministries of Health of the five countries, which worked together with great commitment and a strong cross-border spirit. The initiative aims to achieve elimination of P. falciparum malaria by 2016. By investing in a regional initiative, the Global Fund hopes to become a catalyst for other potential donors to join in the fight against the spread of resistant forms of malaria. Izaskun Gaviria, the Global Fund’s Fund Portfolio Manager for RAI, said the stakes of the initiative go far beyond the Greater Mekong Sub-region. If resistance were to reach India or sub-Saharan Africa, where most malaria cases occur, the public health consequences could be disastrous: artemisinin-based combination therapy (ACTs) is the mainstay of treatment for uncomplicated P. falciparum malaria. Expanding ACTs in malaria-endemic countries has been vital to the recent success in reducing the global malaria burden, which included a 49 percent drop in mortality rates in Africa since 2000.
In 2011, 278 million ACT treatment courses were delivered worldwide by manufacturers to endemic countries – up from 11 million in 2005. Because there is currently no drug available that could replace ACT, the loss of ACT as an antimalarial would bring huge loss of life, before a new anti-malarial drug could become available. “The RAI will join forces with all key partners,” Gaviria said, adding that a high level Regional Steering Committee that will oversee the RAI has all the key stakeholders (national, regional and international) to ensure the initiative builds on efforts currently underway. The grant is a reflection of the game-changing nature of the Global Fund’s new funding model, which strives for strategic investments and promotes interventions where they are most needed.
The main weapons in the RAI initiative include long-lasting insecticide treated nets and targeted indoor residual spraying, as well as case management in areas where there was evidence of delayed response to ACTs or at risk of spread of resistant parasites. Gaviria said there will be a special focus on migrant populations living and working in border areas. The grant is also aimed at helping to halt the marketing and sale of oral artemisinin mono-therapies, which threaten the long-term usefulness of ACTs. It will also set up a rigorous surveillance system linked to control of outbreaks and therapeutic efficacy studies in sentinel sites. Based on disease burden and financial gap analysis, the funds have been allocated as follows: Myanmar 40 percent, Cambodia 15 percent, Viet Nam 15 percent, Thailand 10 percent, and Laos 5 percent; and 15 percent for the inter-country component. China will provide technical support to RAI by sharing experience and best practices. “The momentum is right to achieve a great collective impact in the five countries and beyond,” Gaviria said.