How Criminalizing Homosexuality Hurts Global Health


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Yesterday, Uganda’s President Yoweri Museveni signed a law to enforce much stronger punishment for homosexuality, which technically has been illegal since colonial times. With the passage of this bill, first-time “offenders” can face 14 years in prison, with “aggravated offenders” facing life. This is a huge blow to the global LGBT rights platform, but is not the only legal provision passed by a state regarding homosexuality.

Credit: Rebecca Vasie/AP

While United States citizens battle about the giving homosexual couples the right to be legally married, homosexual citizens in many other countries are actually fighting for the right to even be gay. In the past year, we have all been witness to what seems to be a disturbing trend toward intolerance of homosexuality in some countries. Take India, for example. In 2001, the Naz Foundation (India) Trust, an HIV/AIDS and sexual health-focused charitable trust, challenged Section 377 of the Indian Penal Code (IPC) on the basis of unconstitutionality. This section, described by the Hindustan Times as a “relic from the colonial ages,” technically criminalizes anal sex, but can be clearly understood as criminalizing homosexuality. After a long battle, the Delhi High Court decided in 2009 that the section would be amended to exclude consensual sex between adults. Last year, however, India’s Supreme Court overturned the 2009 ruling, stating that only Parliament could make such a decision.

Criminalizing homosexual behavior is most directly a human rights issue, but it also has serious negative implications for global health work in the areas of sexually transmitted diseases (STDs) prevention and treatment. The most notable STD being fought on the global platform is HIV/AIDS, and many global health scholars are concerned about the effect President Museveni’s bill will have on efforts in the country. The United Nations published an article last week, citing many international leaders calling for the decriminalization of homosexuality. Michel Sidibé, Executive Director of the Joint UN Programme on HIV/AIDS is quoted in this article:

“Uganda was the first country in Africa to break the conspiracy of silence on AIDS — and to give voice to the most marginalized — but now I am scared that this bill will take Uganda backwards, relinquishing its leadership role in the AIDS response.”

According to the article, homosexual men are “13 times more likely to become infected with HIV than the general population.” Making homosexuality illegal will keep men from not only seeking treatment but also getting tested, from fear of being incarcerated and/or prosecuted. In a country where HIV/AIDS is already prevalent, this law could have devastating effects on the progress NGOs and the government have previously made in terms of combating the disease. And in this globalized world where people can travel across the globe in a day’s time, Increased prevalence of any disease in one country can easily threaten the well being of all others.

As of right now, it does not appear that anything can be done to reverse Uganda’s new law. President Museveni ignored even President Barack Obama’s warnings of complicating U.S.-Uganda relations, which is interesting considering that the U.S. is Uganda’s largest donor according to Guardian reports. The most important action we can take now is to raise awareness about how laws like this affect more than just human rights. The world must get involved in protecting these rights if not for feeling responsible for delivering social justice, then to help keep diseases like HIV/AIDS from spreading as best as possible.


When Donors Interfere With Global Health Work—PEPFAR Case Study


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As a student of global health, I have always been a huge proponent of President Bush’s decision in 2003 to introduce the President’s Emergency Plan for AIDS Relief (PEPFAR), which was legislation that would set aside $15 billion across five years for NGOs fighting the HIV/AIDS epidemic. Since then, PEPFAR has been approved to continue to this very day. The program has seen great success, helping facilitate the birth of over one million HIV-free babies. However, I was unaware of the negative aspects regarding PEPFAR politics until very recently. During her talk on Thursday, Dr. Purnima Mane brought up PEPFAR in the context of donors dictating how non-governmental organizations (NGOs) spend the funding provided.

When President George W. Bush signed PEPFAR into law, he also passed legislation that would have an enormous impact on how the money would be spent. The Anti-Prostitution Loyalty Oath (APLO) was a provision that required all NGOs receiving PEPFAR funding to explicitly oppose prostitution in their policies.

While the language on its own may seem harmless, the ramifications of this policy requirement are deep. This oath effectively would prevent the NGOs from providing HIV/AIDS prevention services to sex workers whether it be providing them with education, tests, or contraception.

I was immediately amazed by how little foresight these politicians seemed to have about HIV/AIDS prevention. The disease’s perhaps most well-known type of transmission is sexual intercourse. In many countries of the world, prostitution—although not necessarily held in high regard or socially accepted—is understood as a part of life, and sex workers are generally left to their own devices. The U.S. is easily the most stringent on enforcing laws against prostitution, but it is alone in its strictness; red light districts can be found in so many other countries of the world, sometimes regardless of legality.

So how could it make sense to cut out the people whose profession it was to engage in sexual intercourse? The UNAIDS Inter-Agency Task Team on Gender and HIV/AIDS stated in a factsheet that “preventing transmission among those with high rates of partner exchange is a cost-effective intervention as it can also help avert the spread to members of the wider population.” From a public health perspective, it would make most sense to approach sex workers first since their number of partners consistently increases.

At first, I was surprised by the amount of power legislators—not educated in public health—tried to exert over public health measures. But when I stepped back to see the larger picture, the matter made more sense. What we have here is a classic donor-recipient relationship. Since the United States was committing billions of dollars to fight HIV/AIDS, they naturally wanted to have a say in how it was spent. However, there is a fine line between deciding where to direct funds and telling experts how to spend the money within a chosen field. The United States government, in this case, clearly stepped over this line. The money that they donated could easily be rendered useless because the most effective course of fighting HIV/AIDS would be unacceptable to politicians.

This example goes back to the larger problem of donors not knowing where that line is. It is one matter to have religious or moral beliefs that prevent donors from providing funds to a specific cause—a donor’s way of life should be respected. In addition, donors have the right to decide what category their funds go to—operations expansion, refurbishing equipment, hiring staff, R&D, etc. (we see this a lot when certain grant organizations will only fund specific aspects of an organization). However, donors should not expect to have a hand in running the operations, nor should they try to change the operations. Most of these organizations have developed their system a certain way because it works well. In addition, a given organization will rarely have a truly unique system. In the PEPFAR case, many HIV/AIDS prevention organizations will work with sex workers. Therefore, this is considered a well-researched and effective practice.

The donor-recipient relationship is one that appears and will continue to shift over time. Luckily, the APLO was overturned by the Supreme Court after a number of NGOs filed a lawsuit against the United States government. However, that victory was based on the idea that the oath was a violation of the First Amendment. Overall, I believe that clear and constant communication is the best way for NGOs to actively maintain a healthy relationship with their donors without being subject to any whims. However, some work will be required of donors, i.e. gaining an understanding of how effective public health works, and when to not step into their work for risk of forcing inefficiencies. As the non-profit playing field continues to shift, I feel confident that we will reach a solution for this dilemma.


If you are interested in learning more about the PEPFAR APLO case, here are some additional links:

Balancing Idealism and Pragmatism—CEO Purnima Mane speaks at USC


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One of my favorite parts about attending USC is the Trojan network—not only do we have access to a diverse set of professionals, but we are also offered countless opportunities to learn directly from the pioneers spanning many industries. Yesterday, thanks to USC’s Institute of Global Health, I had the privilege of hearing global health leader Purnima Mane speak on campus.

Dr. Mane is currently the CEO/President of Pathfinder International, an NGO that works on sexual and reproductive health. Prior to entering the health field, she worked as a professor in India. Since then, she has worked at both the United Nations and The Global Fund to Fight AIDS, Tuberculosis and Malaria.

During her lecture, titled “Ideals and Pragmatism in the Global Sexual and Reproductive Health Field: Can They Coexist?,” Dr. Mane touched on a number of important points. Her first statement attacked one of the deepest conflicts that all NGO professionals face, and can be summarized as follows:

One of the perennial challenges we face in the field of global public health is balancing our passion for what we call universal well-being by working frequently with the most marginalized communities and understanding the reality that we live in a world with finite resources for which there is constant competition.

This first critical insight drove the rest of her talk; each point listed below reflects the above theme in some way, shape, or form:

1. The balance between acknowledging the cooperation with other institutions/organizations and definitively measuring how much your organization has individually contributed. The non-profit world is ever expanding, with NGOs popping up with increasing frequency. While these organizations understand the benefits of partnering with and accrediting one another, it is also important that they remain sustainable. Dr. Mane brings up the experience she has had in Ethiopia, where Pathfinder has been working with a number of NGOs as well as the government. She enjoys giving credit to many of these other actors, but realizes that she also needs to actively track and report the exact contributions that Pathfinder has made for the purpose of informing the organization’s donors. This leads to the next point.

2. Changing donor priorities. Keeping donors happy with an organization’s impact, Dr. Mane mentions, is critical. Another challenge that NGOs face is donors that frequently change their priorities. Some donors will alter their goals based on political shifts and accordingly change the terms of their funding. In this case, NGOs face the difficult decision of giving up funding or ending programs in countries that often need them the most. Dr. Mane states that the donor-NGO relationship needs to shift, where donors have less power to make changes in operations that usually take aid away from the most marginalized communities.

3. When and how to focus a program. The issues that NGOs work to remedy are extremely broad—HIV/AIDS, water & sanitation, sexual & reproductive health. It is easy for any organization to try and solve all facets of a global health problem. Such is the current situation with Pathfinder International. To be clear, this is not a problem that organizations face, merely an observation. Dr. Mane stresses that focusing a program has benefits both for global health as well as the organization. Programs that are more focused are “most likely to catalyze (the good that comes about in) providing sexual and reproductive health to the most marginalized communities.” In addition, a narrow focus effectively carves out a niche for an organization, thus better securing sustainability.

4. Why pulling out of a country/region is sometimes necessary. This difficult decision draws from the previous three points. Sometimes, NGOs will comply with donor demands to pull out of regions. Other times, civil conflict or other extraneous circumstances will force leaders to reconsider their operations in a region. Dr. Mane finds this decision as painful as any of us would. However, she notes that leaders must realize that their pulling out of one region may save the rest of the organization. In five years, she says, you still want to be around and be able to make a difference. This question is where compromise, however unfortunate it may be, must come in.

5. Taking on unpopular, emerging trends of work. Being truly innovative in any field requires being able to “see what is ahead of the curve…what is beyond the horizon.” In the case of sexual and reproductive health, cervical cancer prevention and safe abortion care are these emerging projects. However, these issues are unpopular if not controversial, and we find ourselves in yet another clash of idealism versus pragmatism. This becomes a problem in terms of funding. Should organizations push the envelope with these necessary but controversial programs or should they remain in the safe zones and guarantee funding (and thereby their sustainability)? Dr. Mane notes that donors who claim to seek “innovation” often refer to creative growth in technology, not program development. The path of pioneering these new areas in global health is difficult without international recognition, and can lead to an NGO’s downfall if not approached correctly.

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These five points are by no means the only problems that NGOs face. However, they are the major themes in the dialogue about balancing ideals and pragmatism, and will be important to consider as the global health playing field continues to shift. I spoke with Dr. Mane after the event and was able to thank her when I had to leave, but I would really like the chance to meet her again in the future because she is so inspiring. I’m excited to have heard from her yesterday, and I’m looking forward to using what I’ve learned from her as I move forward in shaping my own career. I hope you all can do the same.

Our Very First World Toilet Day


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Credit: United Nations

Credit: United Nations

Happy Toilet Day everyone; it’s our very first yet!

Now there may be many questions surrounding the significance. First, why toilets? Doesn’t that sound a little silly?

Absolutely not. Sanitation is an incredibly important part of our lives—with it, we keep ourselves safe from falling victim to a number of avoidable diseases. When people don’t have access to toilets and instead relieve themselves in man-made holes in the ground and rivers, bacteria spread through the ground and make the soil and drinking water unsafe. Building and maintaining something as simple as a toilet can save hundreds of lives in any given village.

However, as Ban Ki-moon writes in his piece on Toilet Day, sanitation goes beyond health. It is also quite a smart investment opportunity for nations.

Poor water and sanitation cost developing countries around $260 billion a year—1.5 per cent of their gross domestic product.

Now this might sound ridiculous to you, but it really isn’t. If you consider how many people die from diseases caused by lack of sanitation (diarrheal diseases, etc.) in developing countries, add the children that those people might have had, and multiply that population by the GDP per capita, you could probably get a pretty sizable number. Any health initiatives made to help those issues could also be considered part of that cost.

It’s strange to think that a toilet could be such an investment opportunity, but it’s the truth. The data is in front of all of us. Now it is up to developing countries to take the initiative to complete a nationwide project, and for developed countries to keep helping where they can.

FDA Ruling on Trans Fats: Cause for Great Celebration?


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Banning (artificial trans fats) completely could prevent 20,000 heart attacks and 7,000 deaths from heart disease each year, the F.D.A. said.

This quote comes directly from Sabrina Travernise in her NYT article titled, “F.D.A. Ruling Would All But Eliminate Trans Fats.” I’ve been pondering this statement—as well as the entire trans fat situation—for the past week, and I’m still conflicted how I feel about this situation. There are two sides to this situation:

The Initial Euphoria

Yes, it’s exciting. As Travernise covers in her NYT piece, there are many positive effects we can expect. Many foods will be healthier than they once were. As mentioned in the above quote, the number of heart attack deaths will decrease greatly. And we can’t forget how important it is that the FDA was actually able to pass such a powerful ruling. Companies that make oils will now have a much higher standard to which they must hold themselves. This shows that the FDA is a force to be reckoned with, that it’s not just an organization that lets corporate America run entirely amok.

The Subsequent Sadness

This is where the euphoria stops. As happy as I am that this rule has been passed, I am reminded of the sad fact that this is only one ingredient that is abused. But what about all of the others that cause heart disease and so many other noncommunicable (not to mention avoidable) diseases? “Frostings, microwave popcorn, packaged pies, frozen pizzas, margarines and coffee creamers”—all foods with trans fats that Travernise mentions—have many other ingredients that, in excess, can also cause health problems. Frostings are high in sugar, and microwave popcorn high in salt. Too much sugar can lead to diabetes, and too much salt can lead to hypertension and eventually kidney failure.


The conclusion that I’ve come up with after this reflection? Yes, let’s be excited about the FDA ruling. But let’s not get lax about the advancement of public health. These victories can slip away faster than they took to make happen. We need to take advantage of the energy we feel now and power forward to develop public health standards and education that really create an environment in which it is easier for people to be healthy citizens. The only way that America can truly become healthier is if we change the attitudes of Americans themselves. We need to build an environment so that eating healthy doesn’t have to be a difficult choice but an enjoyable one. Making rulings to ban unhealthy ingredients is a good first step but can certainly not be the only measures we take. We have to seriously push for real lifestyle reform.

Making an Affordable Market out of Global Health


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I know it’s been a while. I didn’t realize how difficult it is to keep a daily blog, especially when you’re trying to post an intellectual piece on public/global health every day.

Anyway, back to business. I found this article on LinkedIn titled “Design to Improve Global Health.” It showed up in the LinkedIn e-mails that I receive because someone had posted it in a group that I am a part of. Now I get a great deal of LinkedIn e-mails from new discussions on my groups. It’s easy to get overwhelmed and start ignoring these e-mails. But it is because of articles like these that I actually pay attention to many of the links in these endless e-mails.

Krista Donaldson, CEO of D-Rev (Design Revolution), wrote a piece to discuss the ever-visible problem of presenting expensive solutions to health problems without considering whether their use will be affordable by the people that actually desperately need them.

Instead of developing innovations in labs and then trying to convince people to use them, we ought to start with the user and work our way backwards to the lab.

Donaldson tells a story of the lack of access to phototherapy for jaundice-afflicted infants in Uganda. The only technology available for such a problem was extremely expensive and therefore inaccessible for these people. Her company proceeded to develop an equally effective product for one-eighth of the cost, and sold it to the low-income regions.

In this article, Donaldson makes three key points:

1. The power of approaching your intended clients to search for the problems. I mentioned this earlier, but I wanted to emphasize it. People can make the incredible medical technology, but if there are gaps not being served, they aren’t being particularly innovative.

2. The importance of data collection. Donaldson cites that the lack of data outside of western countries prevented companies from knowing about the intense need for phototherapy technology in Uganda. This shows that due diligence needs to be done when making new products. The western market is not the only one to pay attention to. Studying the needs of low-income countries can prove to be greatly helpful in entering their markets because you can provide them with products and services they actually need.

3. The significance of selling low-cost products instead of giving away high-cost ones. When companies make affordable options, they can help low-income areas while also keeping their own operations sustainable. Creating unaffordable products helps no one. And as Donaldson states, “charging money holds designers and manufacturers—not overworked personnel and patients living in poverty—accountable.”

The original post that Donaldson wrote on this matter is on the World Economic Forum blog. If you want to learn the finer details of Uganda’s jaundice problem and find more examples of developing user-centric affordable global health technology, I would highly recommend you read that piece as well.

GSK and China: Is Big Pharma innocent of bribery everywhere else?

I recently read a few articles about GlaxoSmithKline’s bribery scandal in China, including The Guardian’s piece, and wanted to share a few of my own thoughts.

If you haven’t read about them, here is the gist: British pharmaceutical company GSK is under great scrutiny after executives in China admitted to committing crimes to increase sales. Although paying physicians to fill prescription quotas and faking conference receipts to pay kickbacks to hospital staff are extremes that I have not seen as a common practice, I definitely can say with certainty that “(showering) doctors with money, dinners and all-expenses paid trips in promoting (GSK’s) Botox anti-wrinkle treatment” isn’t a practice the United States is unfamiliar with. Drug companies have been well-known for supplying physicians them with branded paraphernalia (but no longer since 2009) and  bringing the lunch to their private practice offices (this still occurs rampantly).

So should we really be surprised by or have any reason not to believe China’s charges? Not really. If anything, China may be responding in a way the United States should be—with hardline actiond that keep Big Pharma from having such a strong influence. However, pharmaceuticals being one of the largest lobbies, there is little hope that the U.S. will charge the companies for such behavior. Not to mention that freedoms are much more strongly protected in the U.S. as compared to China.

It will be interesting to see how the situation will play out in the next couple of weeks and months. Pharmaceutical companies have not experienced this strong backlash from a country before, so we are in uncharted territory. According to CNN, China has detained some officials and also received confessions from others. In addition, they have punished the hospital staff that took bribes, and will continue its investigation to the fullest extent.

Can you be vegetarian and unhealthy?


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As a vegetarian myself, I cannot stress enough how easy it is to fall into a false sense of security about dietary lifestyles largely considered healthy.

Although I do have it a little easier than my meat-eating friends because they do not have to worry about the unhealthy aspects of meat, I can still definitely gorge on Twinkies and Oreos just as much as anyone who eats chicken and beef.

This post is sort of an extension of my last post on dieting, specifically on the matter of adopting popular dietary restrictions. Vegetarianism is one of them.

I’m not trying to knock the merits of the diet choice. I personally don’t care much for meat, and living a vegetarian lifestyle has served me very well in the taste department (thank you mother). I’m simply trying to point out the mistaken assumptions people make about what it means to eat healthy.

So why do people assume that being vegetarian is automatically a healthier lifestyle. I believe it has to do with obesity. I’d be very interested to learn about how many obese people are carnivores and how many are vegetarian. Not being biased toward vegetarianism, I would imagine that the statistics are skewed negatively toward carnivores. I think I would attribute to that: fried fast foods.

Although I can wash down my French fries with an over-sized soda, I am less likely than a carnivore to find a full meal that I can fry quite like meat. Fried shrimp, roasted turkey, and—of course–fried chicken. Fast food meals are (quite) more often than not filled with meat. And since it is the advent of fast food that has been a strong driving force in the rise of obesity, it seems only natural that meat-eaters would be statistically more likely to become obese. 

I do want to reiterate my point that vegetarians are just as likely to be unhealthy as non-vegetarians. I simply brought up the point about obesity to suggest where people may get the idea that vegetarianism is always healthy. But as I mentioned in my last post, the size of a person (and by extension, their BMI number) is not the sole determinant of health, so one should be careful when making such quick assumptions.

Why I don’t like diets

I never liked the word.

According to the Oxford Dictionary application on my computer, a diet is defined as “a special course of food to which one restricts oneself, either to lose weight or for medical reasons.”

From how I read the definition, the word diet comes with the connotation that the food restrictions/choices may come to an end if the medical reasons end or the weight is lost. But is losing the weight only to gain it back when you return to your unhealthy habits what you should be doing?

The answer is no. Many have been so obsessed with losing weight, and have turned to dieting. But they are wrong to do so. These weight-obsessed people have mistakenly equated losing weight to being healthy, which is definitely not the case (Dr. Peter Attia can attest to that). Although weight loss can be an effect of eating healthier, it is by no means the surest implication of such a change in diet.

Another reason I dislike diets is that different ones trend all the time, and many can have difficulty discerning what course of action is best for them. It is easy to get sucked into one diet’s hype either because of a friend who used it or simply the buzzwords attached to the advertisements. Stick to the facts of nutrition and maintain a balance of the food groups, and alter your diet from there depending on which ones have a more negative (or positive) effect on your health.

So what is the answer? I have to admit that dieting is part of the solution, but only certain aspects. Certain restrictions are necessary to maintain a healthy lifestyle. But these changes cannot end. It may be possible to loosen some restrictions after losing weight, but the discipline must remain. The other part of the solution is living a healthy life beyond food choices. Although eating constitutes an important part of our lives, it is not the only part. A diet alone does not guarantee health; staying active is also an important part of staying healthy and should complement healthy eating to ensure that you are living healthier and protecting your body.


When a middle-class American birth costs more than the royal birth


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When a middle-class American birth costs more than the royal birth

That makes me uncomfortable. When it costs less money for the Duchess of Cambridge to have a baby than a middle-class American mother, there seems to be something wrong.

Obviously, there are a lot of factors at play here, including how the overall health care system works in each respective country. Therefore, the comparison isn’t necessarily on even ground. However, it does force one to ponder why the American way of birth is so much more expensive. Compared to the rest of the developed world, there are considerably great (financial) odds stacked up against women in America when it comes to bearing children. If you’d like to read more about what I have to say about pregnancy in the U.S., you can check out another one of my posts here.