USAID Rule Changes Postponed

An e-mail update from the Global Health Council. . .

-----Original Message-----

From: Global Health Council
[e-mail addresses redacted]
Subj: Update: USAID Proposed Rule Changes
Date: Thu Aug 30, 2007 4:48 pm

August 30, 2007
Global Health Council Opposes Implementation of USAID's Proposed Partner Vetting System

The U.S. Agency for International Development (USAID) announced Aug. 28 that it has delayed plans to implement a sweeping information-gathering and recordkeeping measure originally called the Partner Vetting System (PVS). The measure, which was to take effect on Aug. 27, has been postponed pending further comment from affected organizations and review by USAID.

The comment period has been extended until Sept. 21, 2007. Many Council members have voiced opposition to PVS and the Council recommends that communication to USAID on this issue continue. The Council strongly encourages members to contact both USAID and their members of Congress in opposition to the proposed change.

The PVS, which is now being referred to within USAID as the Anti-Terror Vetting System, would vet individuals, officers or other officials of nongovernmental organizations who apply for USAID contracts, grants, cooperative agreements or other funding, or who apply for registration with USAID as Private and Voluntary Organizations (PVOs).

If implemented, the PVS would require all organizations that apply for USAID contracts, grants and cooperative agreements to submit detailed information about directors, officers and affected employees, including full name, date and place of birth, government issued identification information, address, phone and fax numbers, country of origin and/or nationality, citizenship, gender and profession.

The rule change was issued to ensure that USAID funds are not being used to support activities or individuals "associated with terrorism." Although there is no evidence that USAID funds are supporting terrorist organizations or terrorist activities through USAID partners, the proposal was advanced, according to USAID representatives, in response to criticisms from members of Congress and US security agencies. The Global Health Council does not believe there is an adequate statutory basis for the proposed vetting system.

The Council believes that the PVS may endanger the safety of USAID partner organization staff, is overly burdensome for USAID's partners, unnecessary, and compromises privacy rights and due process. The Council will continue to work with USAID to recommend constructive and feasible measures to address legitimate concerns. Please see the Council's Statement on PVS for sample language to include in your letter to the USAID Chief Privacy Officer. View statement.

Please send your message opposing PVS as soon as possible. The deadline for comments is Sept. 21, 2007.

Please address your message to:

Mr. Philip M. Heneghan
Chief Privacy Officer
United States Agency for International Development
1300 Pennsylvania Avenue, NW
Office 2.12-003
Washington, D.C. 20523-2120
Email: privacy@usaid.gov

Please also send copies to your Member of Congress. www.senate.gov www.house.gov

This email was sent by the Global Health Council.
For more information about the Global Health Council, please visit our website.

Our postal address is
15 Railroad Row
White River Jct, Vermont 05001
United States

Web 2.0 Comes to Public Health

There's a lot about social networking and other Web 2.0 phenomena that Tom Sawyer would recognize--particularly the part about enticing other people to do your work for you. But more and more global health aficionados are taking those first baby steps to explore social networking, shared bookmarking, tagging and other interactive tools. It's still too soon to tell how much is short-lived fad and how much could truly be effective. But here are a few I've come across.

Beth Kanter reports on fund-raising for real non-profits in the virtual world of Second Life.

Emory MPH grad Aaron Wallace has a social networking/job posting site at www.swala.org

Heather and Amber have another public health job site at their worktraveleatsleep site.

Razoo.com hopes to attract more do-gooders with a prize of $10,000. Sign up 100 other like-minded people by Sept. 15 and you have a shot at the money.

ANC Goes for Broke on Madlala-Routledge

Who could believe a single, middle-aged mother of two kids could be such a threat?

Firing apparently wasn't good enough for axed deputy health minister Nozizwe Madlala-Routledge of South Africa. Neither was billing her for the airfare to Spain for an AIDS conference, including the penalty for coming back early when the permission she thought she had received was in fact revoked. The ANC government appears bent on devastating her financially.

Now the defense department is billing her for a trip it alleges was unapproved back when Madlala-Routledge was deputy minister there. Not to be outdone, the public works department is billing for her what it says was unpaid rent for her government housing, which she has since lost.

Meanwhile, in an interview published in the Sunday Argus, Madlala-Routledge likened working for Health Minister Manto Tshabalala-Msimang to the pain and anguish she (Madlala-Routledge) had faced while in detention, including solitary confinement, under apartheid. Some of Madlala-Routledge's friends and supporters have started a fund to help her fight back.

I just can't help following every twist and turn in this conflict between admitting to any sort of a health crisis and the need to maintain political cohesion and demonstrate loyalty to a political party. South Africa's President Thabo Mbeki further laid down his thinking in his weekly online newsletter last week. His latest entry states that basically anyone who criticizes the ANC, including opposition parties, is doing the work of the underground apartheid movement. More to come, I'm sure.

Details of USAID Proposed Rule Change

Not sure why the hyperlink didn't come through on the last post, but until I can fix it, here's the citation from the Federal Register:

http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/07-3330.htm

Update: links in original post "USAID Rule Targets Terrorists But Hits NGOs" are now fixed.

USAID Rule Targets Terrorists But Hits NGOs

Oh dear. More friendly fire in the war on terror.

Passing along this e-mail from the Global Health Council.

See also this update on the proposed USAID rule change.

-----Original Message-----

From: Global Health Council
Subj: Urgent: USAID Proposes Rule Changes
Date: Wed Aug 22, 2007 6:23 pm

August 22, 2007 Global Health Council Opposes Implementation
of the Proposed Partner Vetting System at USAID

The U.S. Agency for International Development (USAID) proposed a sweeping information-gathering and recordkeeping measure, the Partner Vetting System (PVS), to vet individuals, officers or other officials of nongovernmental organizations who apply for USAID contracts, grants, cooperative agreements, or other funding or who apply for registration with USAID as Private and Voluntary Organizations (PVOs).

The Partner Vetting System would require all organizations that apply for USAID contracts, grants and cooperative agreements to submit detailed information about each employee including full name, date and place of birth, government issued identification information, address, phone and fax numbers, country of origin and/or nationality, citizenship, gender and profession. The proposed measure was printed in the Federal Register on July 17. Notice, Privacy Act System of Records, Federal Register, Vol. 72, No. 136, July 17, 2007, Pages 39041-39044. View specific guidelines

The rule change was issued in an effort to improve processes for making sure that USAID funds are not being used to support activities or individuals "associated with terrorism." There is no evidence that USAID funds are supporting terrorist organizations or terrorist activities through NGOs.

The Council believes that the Partner Vetting System is overly burdensome for NGO partners, unnecessary, and compromises privacy rights and due process as envisioned. Please see the Council's Statement on PVS for sample language to include in your letter to the USAID Chief Privacy Officer. View statement

Please send your message opposing the Partner Vetting System as soon as possible. The deadline for comments is Aug. 27, 2007 - the same date PVS is scheduled to take effect.

Please address your message to:

Mr. Philip M. Heneghan
Chief Privacy Officer
United States Agency for International Development
1300 Pennsylvania Avenue, NW
Office 2.12-003
Washington, D.C. 20523-2120

E-mail: privacy@usaid.gov

This email was sent by the Global Health Council.
For more information about the Global Health Council, please visit our website.

Our postal address is
15 Railroad Row
White River Jct, Vermont 05001
United States

ANC to Investigate Madlala-Routledge

The African National Congress now plans to investigate fired South African deputy health minister Nozizwe Madlala-Routledge for her implied criticisms of both President Mbeki and the ANC on AIDS and other matters.

You would think the party would let the whole thing drop instead of further fueling the media storm. All this does is stoke the anger about how Madlala-Routledge, a well-regarded government official, got the boot. But what do I know about politics?

Interesting tidbit: the person charged with investigating Madlala-Routledge also apparently advised her not to resign but instead to let herself get fired on principle.

Meanwhile, I keep reminding myself not to get too distracted by the personality clashes and drama. The key issue here--at least from a health point of view--is what happens to South Africa's National Strategic Plan on AIDS.

President Mbeki is on record as saying he still supports the NSP and that it doesn't depend on the whether or not Madlala-Routledge is in office. That's the prize we should all be keeping our eye on.

Thoughts on South Africa, the U.S. and Buses

There's nothing like going to another country to make you think more deeply about your own. My recent trip to South Africa has me pondering a lot of things here in the U.S. from a slightly different angle.

Economic disparity. While in South Africa, the biggest contrast between haves and havenots that I saw was in Cape Town. We didn't go inside any of the lovely mansions high on the hills hugging the coastline. But it was easy to imagine what they must look like inside.

Just a few miles away on the Cape Flats, at sea level, we visited Dunoon, one of the poorer neighborhoods, where the majority of families love and work and play in crowded metal shacks. They have basic sanitation--public outhouses--and electricity. But in many cases cooking food or washing clothes still occurs over open fires.

Not surprisingly, fast-spreading fires are a huge problem in these areas. As is flooding, given the location. The week after we left, Cape Town was hit by four big Atlantic storms in a row, causing a lot of devastation. Other problems include high rates of tuberculosis and other respiratory diseases, crime, the lack of economic and educational opportunities.

What do the folks living up on the hills owe, if anything, to the people on the Flats? Even the middle class have their rewards, a comfortable life, food on the table, a car or two. Do they have anything in common--other than their humanity--with the people on the Flats?

Now back to the other side of the Atlantic. You see tremendous contrasts every day in New York City, which is my home. They may not be as great as in Cape Town, but they are most assuredly there--at least until they start seeming familiar and disappear from consciousness.

And in the past few days in Cambridge, Mass., this great bastion of higher learning and privilege in the U.S., I'm struck by the contrasts.

Just one anecdote about buses to make the point. I have a whole theory about buses and what riding buses can tell you about a community, which I may expand on in another post some day.

Anyway, Harvard provides a shuttle bus from the university campus to the medical school and school of public health. The service is free to those with a Harvard ID. So yesterday, after I got my ID (I'm starting to feel more official now), I tested it out by taking the shuttle over to the school of public health.

I didn't think much of it at the time, but everyone on board looks very serious and pre-occupied, checking out their Treos, reading books, studying texts, listening to iPods. All very professional-looking.

Later in the day, I took one of Cambridge's public buses, along Massachusetts Avenue. There was a much greater mix of people and the French-speaking couple in front of me--possibly Haitian--were clearly none too sure exactly where they were going or which stop would bring them closest to their destination.

No great conclusions. It was just a flash, an impression of contrast while riding two different buses. But it made me wonder, What, if anything, would ever bring the passengers on these two vehicles--the shuttle and the public bus--together. What, if anything, do they owe each other?

Manto Drama Enters Third Week

Just when you thought the news from South Africa couldn't get any weirder. The Sunday Times published a report yesterday that categorically declares that Minister of Health Manto Tshabalala-Msimang is an active alcoholic. Furthermore, it says doctors at a Johannesburg hospital where she received a liver transplant earlier this year covered up the fact that her own liver had failed due to alcoholic liver cirrhosis. The South African newspaper goes on to say that she has been seen drunk since the transplant.

Oh yeah and Tshabalala-Msimang was convicted of stealing jewelry and other items from patients at a hospital in Botswana, where she used to work in the 1970s.

As bizarre and damaging as Tshabalala-Msimang's pronouncements on AIDS have been, I'm troubled by how much of her personal medical records are being made public in this ongoing scandal. Privacy rules should cover everyone not just our friends.

On a personal note, I picked up a rental car over the weekend, packed up some clothes and my laptop and moved in to my new digs in Cambridge. Still learning where the post office, grocery store and other important services are located. Have already started to meet some of the other Nieman Fellows. Orientation begins next week.

CARE, Utah Mine Deaths, South Africa

CARE. Three cheers for CARE, which reject $45 million worth of food aid from the U.S. government, arguing it does more harm than good.

As the BBC reports,

"CARE criticised the way US food aid is distributed, saying it harms local farmers, especially in Africa. It said wheat donated by the US government and distributed by charities introduced low prices that local farmers are unable to compete with."

Utah Mine Deaths. True to its promise to try to take up where Confined Space left off, The Pump Handle has provided lots of good behind-the-headlines coverage of the mine disaster in Utah that has trapped six miners and now killed three rescuers.

See especially Celeste Monforton's post on the need for tracking systems for trapped miners. Monforton has a masters in public health and was part of a team that investigated the Sago and Aracoma Alma coal mine disasters on behalf of West Virginia Governor Joe Manchin.

South Africa. Meanwhile in South Africa, not even the conviction of apartheid-era security officials has stemmed the anger over the firing of deputy health minister Nozizwe Madlala-Routledge. Thobile Ntola of the South African Democratic Teachers Union criticized President Mbeki's handling of the whole affair at one of the union's branch meetings.

“Tell me what kind of a president would preach gender equality and at the same time fire a woman during Women’s Month?" Ntola was quoted as saying by the Daily Dispatch. “This proves that in this African National Congress that was formed to benefit the poor, you cannot voice what you believe will serve in the interest of one Mambhele on the street.”

While Xolela Mangcu writes in Johannesburg's Business Day that "President Thabo Mvuyelwa Mbeki has become an albatross around the neck of our political culture."

"At every turn, Mbeki has tried to pass himself off as an interesting intellectual, irrespective of whether his ideas are relevant to the reality of the population," Mangcu writes. "That surely must partly explain the instinctive denial. If it does not emanate from the "private lair of his skull" then it cannot be true. It's the perpetual intellectual quest for originality gone haywire.

I am from Eastern Cape and everyone there knows that you send your relatives to public hospitals only to die," Mangcu continues. "Not long ago, the distinguished writer Phyllis Ntantala described those hospitals as morgues after her harrowing experience there."

Today, President Mbeki responded to continuing criticism of his firing of former deputy minister of health Madlala-Routledge in his weekly "Letter from the President" as follows:

Some in our country and others elsewhere in the world, including the media, have acclaimed Ms Madlala-Routledge as a great heroine, before and after her dismissal, on the basis that she seemed to demonstrate intellectual and personal "courage" by defying the obligation to speak and act as part of a collective. In this regard, in her 10 August press conference, she made a point of emphasising her obligation to be accountable to the media.

Collective responsibility

With regard to all this, I must make the point absolutely clear, without equivocation or qualification, that while the ANC serves as government, in any of the three spheres of government, freely elected by the people, it will ensure that its members respect the principle and practice of collective responsibility.

None of the members of the ANC deployed in government will be treated by our movement as heroes and heroines on the basis of "lone ranger" behaviour, so-called because of their defiance of agreed positions and procedures of our movement and government.

For more posts on Madlala-Routledge, click here.

Working For Water; Saving Lives

The scene: Cape Town’s world-famous Table Mountain, part of the spectacular sandstone spine of the Cape Peninsula.

The guy in the green National Parks jacket: Paddy Gordon (pictured above).

The out-of-towners: six journalists from the U.S. and U.K. on a traveling seminar sponsored by the Kaiser Family Foundation.

Gordon talked to us about how eucalyptus trees and other plants that were brought to South Africa over the past 300 years have played havoc on the natural ecology of the country's majestic mountains. Eucalyptus trees, in particular, suck up lots of water from the ground robbing the life-giving liquid from native plants.

But eucalyptus trees are very hard to uproot and get rid of. Although it’s easy to teach someone how to do it, you need lots of hands to accomplish the task. Hmmm. Anyone else see the makings of a good idea?

Enter Working for Water, an initiative of the South African government, which marries the need for ecological restoration with the demand for lots of jobs for unskilled laborers in very poor comunities like Khayelitsha.

But it doesn’t stop there. Working for Water, which was launched in 1995, also teaches job skills like basic book keeping and bidding for contracts so that workers can eventually create their own businesses. In addition, the initiative conducts regular AIDS training programs as well.

Good health requires more than healthcare workers and clinics. You also need clean drinking water, jobs, basic sanitation, jobs, adequate housing, jobs, education, jobs, legal rights, and jobs. Well, you get the point.

Regular employment makes a huge difference in how healthy a community--and often even a natural environment--can be. Working for Water is helping to make that difference.

Having Your Say: Pandemic Flu

Stock up on face masks. Before I left the U.S. (and my computer) last month, I put up a poll question asking you to guess when a flu pandemic might strike. Now without further ado, the unscientific results: 7 out of 15 loyal respondents believe that a pandemic flu will hit in the next five years. Five voters thought it would strike in five to ten years and three opted for 10 to 50 years. No one believed flu pandemics are a thing of history.

Madlala-Routledge Stands Alone

Party discipline holds--for now. All government officials and ANC members with political ambitions are distancing themselves from South Africa's fired deputy health minister, Nozizwe Madlala, who in the matter of a few short months had distinguished herself as an honest and refreshing voice on the HIV/AIDS crisis.

At a press conference last Friday, Madlala Routledge mentioned in passing that she had talked with three different government ministers who were concerned about conditions at Frere Hospital in the Eastern Cape. On Tuesday, all three released statements declaring that they had NEVER EVER invited her to check out the problems at the troubled hospital.

Madlala-Routledge visited the hospital on her "own initiative," they said, and they had NOTHING to do with it.

Can you spell Catch-22? Two doctors at Frere hospital were also suspended. One apparently got in trouble for writing directly to President Mbeki that conditions at the hospital really were bad. (She should have gone through channels) The other was suspended for allowing conditions at the hospital to deteriorate so badly. (Yes, even though an official health ministry task force decided things were quite normal at Frere.)

Race considerations often lurk beneath the surface of South African politics. And there's no doubt that the Democratic Alliance, a mostly white opposition party, is making a lot of hay over Madlala-Routledge's firing. But South Africa's minority whites aren't the only people who are upset.

Dr. Olive Shisana, who used to be director-general of the Ministry of Health until she was axed as well, has come out in support of Madlala-Routledge as has Zwelinzima Vavi, the General Secretary of the Congress of Southern African Trade Unions--although he apologized to the families of dead ministers after making a remark about deadwood in the Cabinet. And Dr. Kgosi Letlape of the South African Medical Association called Madlala firing "regrettable."

In truth, Madlala-Routledge's departure must be seen as a power play by President Mbeki and a warning to others who don't show him loyalty ahead of the ANC's December meeting to choose a party president. Although Mbeki cannot run for a third term as president of the country, there is apparently nothing to stop him from being chosen as head of the party for a third term.

It would be the height of irony if axing the deputy health minister--which seems to be achieving the desired political results so far--strengthens the hand of a populist like Jacob Zuma, a longtime Mbeki rival, who is positioning himself to be ANC's next leader as well as the head of the government. As I learned on my recent trip to South Africa, many people in the professional classes--black, white and other--fear that Zuma could become South Africa's own Robert Mugabe. They would rather bumble along with Mbeki than risk a Zuma election.

Meanwhile, Madlala-Routledge has been busy house-hunting. She loses her government-funded home and office at the end of September and will be taking a significant cut in pay as well. (She is still a Member of Parliament.)

For related blog entries on Madlala-Routledge, click here.

Lead Kills Whether in Toys or Jewelry

Say what?! It's against the law to put lead in toys but the U.S. still does not ban lead in jewelry. Lead-containing trinkets are particularly dangerous if swallowed since that can lead to acute lead poisoning, resulting in seizures, brain damage and even death.

Under growing public pressure, the U.S. Consumer Product Safety Commission is now considering adopting a ban on lead in children's jewelry and has asked for comment.

Meanwhile, toy-making giant Mattel is set to announce another recall of lead-tainted products manufactured in China.

Update: complete list of toys in latest Mattel recall.

Cross-posted in The Health Media Watch.

South Africa's Health Minister Accused of Drinking in Hospital

Last week's media storm in South Africa over the firing of deputy health minister Nozizwe Madlala-Routledge shows no signs of letting up. President Thabo Mbeki took the unusual step of releasing his letter of dismissal to the media over the weekend. In it, he declared that Madlala-Routledge was let go because of her "inability to work as part of a collective, as the constitution enjoins us to."

Mbeki was responding to continuing outrage from the government's coalition partners and others that Madlala-Routledge, widely regarded as honest and competent, had been fired instead of her former boss, the often erratic Health Minister Manto Tshabalala-Msimang.

But the President's move was quickly overshadowed by an explosive report in The Sunday Times of South Africa, accusing Tshabalala-Msimang of a "booze binge" while in the hospital two years ago for shoulder surgery.

Tshabalala-Msimang has in the past denied having an alcohol problem and press reports suggested she is considering suing The Sunday Times over the allegations. The newspaper's editors say they stand behind their story, which was based on a five-month investigation as well as leaked hospital records.

Read President Mbeki's letter to Madlala-Routledge on the official South African government site.

For related blog entries on Madlala-Routledge, click here.

Madlala-Routledge on True Leadership

Update: See video of Madlala-Routledge speaking out on why she was fired.

South Africa's sacked deputy health minister shared some incredibly thoughtful and eloquent reflections on the fight against AIDS in South Africa in this post-firing interview with The Independent. I highly recommend the article, which was written by Katherine Butler, who I got to know a little while traveling in South Africa last month.

"I don't regret saying that our political leaders should show the way and undergo HIV testing, in public," Nozizwe Madlala-Routledge told The Independent. "We need at least 25 million people tested. When you are in charge of the country, you have to offer leadership." Read the rest of Madlala-Routledge's comments here.

I've searched the Internet for an audio recording of today's press conference at which Nozizwe Madlala-Routledge spoke about her firing. Although the press conference was carried live on Cape Talk Radio, I still haven't found anything other than summaries and selected quotes. (Update: here's the video of Madlala-Routledge's comments.)

But the ANC's two coalition partners in government are clearly unhappy with President Mbeki, who axed Madlala-Routledge earlier this week. The Congress of South African Trade Unions said the firing would "deepen the culture of sycophancy among government ministers and officials," while the South African Communist Party, of which Madlala-Routledge is a member, said if they had been consulted, they "would have advised otherwise."

For related entries on Madlala-Routledge, click here.

Madlala-Routledge Tells Why She Was Sacked

South Africa's popular and now former deputy health minister told a press conference in Cape Town today that she was sacked because she visited a maternity hospital and publicly declared that deplorable conditions there constituted a "national emergency."

Nozizwe Madlala-Routledge also explained that she thought she had Presidential permission to attend a meeting about AIDS vaccines in Madrid when she left, only to discover when she arrived in Spain that it had been revoked. She then returned to South Africa without attending a single session.

Both issues came up when she was called to President Thabo Mbeki's office earlier this week and asked to resign. Madlala-Routledge refused, so Mbeki fired her.

Madlala-Routledge had won plaudits both in South Africa and internationally for her open and honest discussions about AIDS in that country and the need to bring treatment to a greater proportion of the population. Her boss, Health Minister Manto Tshabalala-Msimang, by contrast, had famously promoted ineffective remedies like beetroot and garlic for the treatment of AIDS.

It's not the first time that a politician has gotten rid of a more popular deputy. But that doesn't explain why a top doctor at the maternity hospital in question, who wrote a letter to the President supporting Madlala-Routledge's call for reform at the hospital, is also reportedly facing disciplinary hearings for her views. Still no word yet on whether Dr. Nomonde Xundu, chief director of HIV/Aids, Tuberculosis and Sexually Transmitted Infections at the Ministry of Health, has been able to renegotiate her "resignation" either.

For related entries on Madlala-Routledge, click here.

Even the Timid Get Axed in South African Health Shake-Up

Manto Tshabalala-Msimang is definitely consolidating her hold on the South African Ministry of Health. Not only has her outspoken deputy minister been fired, but her most senior AIDS expert, Dr. Nomonde Xundu, has reportedly tendered her resignation.

Dr. Xundu never contradicted her boss in public and faithfully used the government-approved terminology of "HIV and AIDS," which sees HIV infection and AIDS as two separate conditions rather than a continuum of illness. But Xundu clearly accepted that HIV causes AIDS and that anti-retroviral treatments are necessary to save lives. A report on news24.com says Xundu is trying to negotiate an extension of her contract.

For related entries on Madlala-Routledge, click here.

Deputy Health Minister Sacked in South Africa

Disturbing news from South Africa. President Thabo Mbeki has sacked Nozizwe Madlala-Routledge, the deputy minister of health. It seems Madlala-Routledge was just too good at her job, talking about the need for better AIDS prevention and treatment programs and encouraging ANC leaders to set an example by getting HIV tests in public.

The most immediate casualty, apart from the deputy minister herself, may be South Africa’s newly developed National Strategic Plan for AIDS (2007-2011), a highly regarded and forward-thinking blueprint for tackling the crushing HIV epidemic in that country. Nozizwe Madlala-Routledge played a major role in getting the plan pulled together, which was developed with input from many health experts inside and outside of government as well as civil society leaders. Madlala-Routledge was able to take that leading role because her erstwhile boss, Minister of Health Manto Tshabalala-Msimang, was out of the picture for a while with a serious illness that eventually required a liver transplant earlier this year.

The precipitous move is another sign of increasing strain within the African National Congress, as it prepares itself for party elections in December. Today, executives of the ANC's Women's League questioned the firing of Madlala-Routledge, coming as it did on the eve of Women's Day in South Africa. No word yet on the reaction of the South African Communist Party, which is a coalition partner of the ANC and of which Madlala-Routledge is a leader. (She is also a Quaker.)

The last straw for Mbeki and Tshabalala-Msimang, who has apparently made a full recovery, was when the deputy minister of health made an unannounced visit to a maternity hospital in the Eastern Cape. There, Madlala-Routledge found that the appalling conditions described by a local newspaper report were in fact true and that mothers and babies were dying needlessly.

Madlala-Routledge’s call for reform at the hospital was treated as insubordination by the Minister of Health. The ANC newsletter attacked the press reports as "dramatic but false" even as the Minister of Health began launching many of the needed changes.

The cause given for the deputy minister's removal was a trip she had taken in June to an AIDS seminar in Madrid, allegedly without Presidential permission. A one-sided press report suggested that she left in defiance of Mbeki's decision but rumors were rife in South Africa that she had been given permission to go, which was then revoked while she was in the air. As soon as she learned about the change, she took the next available flight home, without even attending the conference.

For related entries on Madlala-Routledge, click here.

Grandmothers Against Poverty

It was obvious everywhere we went in South Africa that grandmothers are the glue that holds most of society together, particularly in rural and impoverished areas. Before coming to South Africa, I had assumed that that was primarily because of the traditional role that grandmothers played in the care and rearing of their grandchildren while parents were busy at jobs far away.

While travelling to six of the country's nine provinces, however, it became clear that grandmothers also are a major economic force in large part because they receive a little over 800 Rand per month (about US $115) in old-age pension benefits. I met many older women--some of them in their 70s and 80s--who were caring for their grandchildren and even great-grandchildren, clothing them, feeding them, paying their school fees out of this modest pension benefit.


(Leonora Msikinya, 85, (pictured above) who I met in Ethembeni in the Eastern Cape has dedicated the remaining years of her life to fighting HIV by talking clearly in her community and church about sex, pregnancy and HIV. She has even been featured on anti-AIDS billboards throughout the country.)

What became very obvious to me, while visiting with these women and their families, is that they and their old-age pensions are also an important bulwark against poverty.

Indeed, a June 2007 study by Charles Meth, who is associated with both the University of KwaZulu-Natal and the University of Cape Town, concludes that of the three major social grants available in South Africa (old age, children support, disability), "old age pensions have the greatest impact on poverty. In 2004, the approximately two million pensions raised about 1.5 million people in 600 000 households over the poverty line."

Which brings me to my next questions: What hope is there for you if you're poor and don't have a grandmother in South Africa? Would a modest basic income grant for those living on less than a dollar a day--something that Archbishop Desmond Tutu brought up again at a church meeting in Johannesburg in July, but which doesn't seem to be getting much traction among the powers that be in South Africa--make a difference?

Using Search-Engine Journalism to Get Your Message Across

As I said back in June in a talk at the Global Health Council, search-engine journalism is changing the way interested folks get their topic in front of interested journalists. If you blog about your issues with insight and creativity, journalists will eventually find you, rather than waiting for you to cultivate them.

It's not that journalists necessarily read that many blogs or check that many web pages on a daily basis--there are just too many sites for that to be a practical approach. Our secret weapon is often a "Google alert" or a Yahoo keyword search that brings us some fairly well targeted urls that contain postings of interest. Indeed, I often create alerts based on people's names in addition to certain topics because I just like the way some people think--no matter what topic they write about.

Case in point: Ethan Zuckerman's ideas on incremental infrastructure, which he posted on his blog, caught the interest of an editor at the Boston Globe, who invited Zuckerman, a fellow at the Berkman Center for Internet and Society at Harvard, to write about the topic for the Ideas section of the newspaper. Basically, Zuckerman sings the virtues of small-scale, privately financed infrastructure that can be incrementally scaled up as opposed to many of the large-scale, government-and aid-financed programs that have become such white elephants in many parts of Africa.

Zuckerman's points on infrastructure are interesting and worth consideration. But as far as I can tell from his blog, he didn't call up a journalist to "pitch a story." An editor at the Boston Globe found him and his ideas in that incredibly democratic marketplace of ideas, the Internet.

For the record, I learned about Zuckerman's post through an RSS feed to my personalized iGoogle homepage. Mine is a modest iGoogle page that helps me follow my top about 50 news and blog sources for information. I use Google Reader, which also uses RSS feeds, to share some of those selections on a sort of mini-global health blog that also lives on the right hand side of the blog.

RSS--for really simple syndication--makes it more likely your creativity and insight will get picked up by people who are actually interested in your issues--and not just random searchers on the Internet.

Balancing Human Rights And HIV Testing

There's a growing movement to declare access to basic healthcare as a fundamental human right. And there's a lot to commend in this push. But great ideas and good intentions don't always guarantee desired results on the ground, as I learned in my recent trip to South Africa.

A case in point: the clash between those who champion voluntary counselling and testing (VCT) for HIV with the those who argue for the so-called opt-out model.

VCT grew out of the early days of the AIDS epidemic when people's legal rights were getting trampled right and left in housing, on the job, in schools and in clinics and hospitals. Back when there was no treatment for HIV, when AIDS was a new and terrifying scourge, it made a lot of sense to make sure that everyone understood before getting tested for HIV, what the test involved, what it meant to be HIV-positive, who could use that information and what your legal rights were.

But now that we have lived with AIDS for 25 years, now that there are treatments (albeit no cure or vaccine), now that anti-discrimination laws are stronger, voluntary counselling and testing may actually be doing more harm than good.

Or at least that's the feeling of a couple of doctors I spoke with in South Africa.

By making HIV testing such a big deal in that country, VCT has actually increased stigmatization, in their view, particularly in rural areas where all your neighbors go to the same clinic and know which chairs and which doors are designated for HIV testing and counselling. And in fact, studies show that under VCT programs fewer South Africans who actually are HIV positive opt for testing.

As an alternative, a few South African healthcare workers are trying the opt-out model for HIV testing. Patients still get counselled about HIV but it's part of a broader panel of tests--for example, prenatal tests that look for Rh factor, diabetes and high blood pressure. And instead of actively making a decision to be tested (call it opt-in), the active decision after the counselling is not to be tested. In other words, if you do nothing, you'll be tested. But your rights are preserved by an "opt-out" option.

The opt-out approach has worked in Botswana and is being championed by the Centers for Disease Control for use in the U.S. It's gotten some pushback from those who were trained in and have championed voluntary counselling and testing. There is a legitimate human rights concern here--AIDS discrimination is still rampant, particularly in areas of extreme poverty. But being inflexible about how human rights are expressed or sticking with the first human rights response for too long can also lead to harmful and even fatal delays in care.

Jobs in Women's Health, PEPFAR, Climate Change

A few job listings that have come to my attention:

Senior communications advisor, President's Emergency Plan for AIDS Relief.

Director of Development, International Women's Health Coalition

Senior Program Officer, IWHC

Program coordinator for building resilience to climate change in Asia (based in Bangkok), Rockefeller Foundation

News Flash: Talking About Sex is Fun

I'm still trying to figure out what I think about loveLife, the ubiquitous sex education and teen-empowerment organization whose goal is to reduce HIV transmission among young people in South Africa. LoveLife's Y-Centers were frequent destinations for myself and my fellow journalists in July--all organized by the Kaiser Family Foundation for our traveling AIDS Seminar.

Clearly, Kaiser made a point of taking us to all these loveLife groups because the foundation is a major supporter--to the tune of more than $150 million about $80 million over the years. Some of us joked that we were going to know loveLife's slogans better than the kids did by the end of our trip.

More seriously, questions have been raised in the international press as to whether loveLife's approach has any effect on HIV rates. We also heard from parents who said their initial impression of loveLife was that it was a place where their kids went to find sex rather than to refrain from sex.

And it's absolutely true that loveLife's pamphlets and workbooks are pretty frank. One exchange between cartoon characters Miriam and Maxwell has Max telling Miriam that he has to have sex with her or his "balls will turn blue." Miriam replies, "Good. Then I can hang them on the tree this year for Christmas ornaments." That sort of no-holds-barred exchange probably goes a long way towards explaining why the Global Fund no longer supports loveLife.

Of course, anyone who has been around teenagers or remembers being a teenager knows that this is the way teens talk--the myth about blue balls, for one, having been around for generations.

Denying sexuality hardly seems to be the answer. Later in our trip, we heard anecdotal reports that anal sex rates are on the increase in South Africa because of the number of abstinence programs that promote virginity before marriage as well as the growing popularity of hymen examinations for young brides. Talk about unintended consequences. Unprotected anal sex is a much more efficient transmitter of HIV than unprotected vaginal sex. (See also this new report by Kristen Underhill and colleagues in the British Medical Journal, which concludes that abstinence-only programs have no effect on pregnancy or HIV rates in rich countries.)

Another challenge when trying to figure out how effective loveLife's programs are is the fact that official UNAIDS statistics are broken out by fairly large age groups. Teens are covered in the 15-to-24 year-old bracket. By not breaking out the lower end of the age group--15 to 17 or 18--you're not getting a good picture of whether prevention messages targeted at teens are working and then failing as they grow older.

I keep coming back to the energy and enthusiasm of the teenagers we met at the loveLife programs that we visited and the commitment of their peer educators--dubbed "groundbreakers" in the loveLife lexicon. There was certainly a sense of possibilities, of optimism for the future, of a life to live for and a reason to avoid becoming infected with HIV.

That positive spirit was quite a contrast with that of so many of the adults we met on other portions of our trip. I'm not a trained psychologist or anything but it certainly seemed to me there was a lot of depression amongst the adults we met. The end of apartheid did not magically erase the legacy of racism, extreme poverty, missed opportunities and mistrust. There is still so much left to do.