Typhoon Ketsana, the massive storm that wreaked havoc in the Philippines, continues to have consequences. But for a group of 43 community health workers, nurses, and doctors now languishing in a military prison, the consequences were way beyond their worst nightmares.

The group was taking part in a week-long training seminar organised by the Community Medicine Foundation, to build first-responders capacity at provincial level, so the effects of disasters like Ketsana could be mitigated.

Participants had come from all parts of the Philippines to a farm in Rizal, east of Manila, owned by Melecia Velmonte, a leading infectious diseases specialist who regularly lends her farm to medical organisations for conferences, training sessions, and meetings.

But the Armed Forces of the Philippines, viewed the seminar as something entirely different. They insist that what was going on was a terrorist training camp where participants were being trained to make explosives. At first light on Feb 6 they swooped on the farm to achieve what they described as their biggest-ever mass arrest of insurgents.

“Around 6.15 am, 300 heavily armed elements of the military and police forced their way into the farm”, says a report released by the human rights Karapatan (whose deputy general secretary is married to one of the doctors arrested during the raid).

“At gunpoint, the military forced the caretaker to open the gates. Inside, the soldiers fanned out to different directions. They also kicked the main door to get into the building.”

“When Dr Velmonte and her son, Bob demanded for a search warrant, they were merely brushed aside by the military. All medical practitioners and health workers, were ordered to line up at the garage, frisked, and handcuffed…The male victims were then blindfolded with old shirts brought in by the soldiers and secured with packaging tape. All of the personal belongings of the victims were also taken by the military.”

While the medical workers waited outside, cuffed and blindfolded, wondering what would happen next, the soldiers searched their sleeping quarters. There they found, according to an official announcement made later that day, C4 (composition 4) explosives, a gun with seven bullets, and three hand grenades. One of the grenades was allegedly found under someone’s pillow.

“Would you hide a grenade under your pillow?” asked Roneo Clamor, husband of one of the detainees, Mary Mia-Clamor, during a press conference held by relatives and friends to demand that the 43 individuals be freed immediately.

Their demands fell on deaf ears. The health workers remain locked up in a military camp in Rizal—the women all in one room, the men in smaller cells in ones and twos. Relatives who have been able to see them for short periods say they have been tortured, and subjected to lengthy interrogation, sleep deprivation, and, in some instances, sexual abuse.

Their military captors say the interrogations have yielded evidence that some were involved in attempts to abduct senior commanders involved in counter-insurgency operations. However, this has yet to be tested legally. The Philippines’ supreme court issued a writ of habeas corpus commanding the military to produce the 43 in court on Feb 12, but they did not, citing a “lack of resources”. They eventually produced the health workers in court on Feb 15.

To outsiders the two versions—a disaster medicine training seminar and a terrorist training camp—are so far apart, the arrests seem absurd. But those familiar with the extrajudicial arrests, detentions, and killings often done in the name of counter-insurgency by a powerful, well funded military poorly controlled by the judiciary or the elected government, are not surprised.

Doctors who choose to become community health specialists and work with poor people in the provinces, are automatically considered leftists and targeted. “It’s sending a really bad message—not only to the health sector…we already have problems with our health-care delivery and now doctors are frightened of going to the provinces”, said Gene Nisperos of the Health Alliance for Democracy.

Margaret Harris Cheng

Late last year, the Times of India ran an advertorial on behalf of the asbestos industry. Entitled “Blast those Myths about Asbestos”, it began by asserting “asbestos is a naturally occurring material”. Readers were assured that “only safe white fibre is used in manufacturing of asbestos cement products in India”; and that the “problems” other countries have encountered “are not relevant in the Indian context”.

India’s surging consumption of asbestos, the industry’s hefty political and economic clout—of which the Times advertorial was one manifestation—and the country’s poor record of worker protection, has alarmed experts. A sizeable burden of asbestos-related disease is inevitable. But if current trends continue unabated, the public health consequences will be felt into the next century.

Worldwide, at least 90 000 people die every year from illnesses resulting from occupational exposure to asbestos. However, this number only takes into account workers and ex-workers who have been identified with asbestos-related lung cancer, mesothelioma, and asbestosis. But asbestos has also been linked to laryngeal and ovarian cancer. Factor in asbestos-related illness among individuals whose work history has not been recorded, the family members of those who work with asbestos, and people living near asbestos factories and mines, and the death toll is much higher.

The lengthy latency period of asbestos-related malignant diseases—in some cases more than 40 years—means that even in countries that no longer use the material, the disease burden continues to rise. The UK, for example, banned all forms of asbestos in 1999 but at least 3500 people die from asbestos-related illnesses every year, and this figure is expected to increase to about 5000 in the coming years.

Chrysotile (or white asbestos) is the only form of asbestos still being mined—it constitutes more than 90% of all asbestos used throughout history. Canada—from where India sources much of its asbestos—is home to the Chrysotile Institute; an influential organisation funded by the Canadian Government, which lobbies internationally on behalf of the material, often hosting events in Canadian embassies. Indeed, Canada has been instrumental in stymieing efforts to have chrysotile listed in the Rotterdam Convention, a UN registry of hazardous materials, which requires “prior informed consent” before they can be exported.

The Chrysotile Institute distinguishes between chrysotile and amphibole forms of asbestos, contending that the former is not so dangerous and can be safely used. Crucially, the Chrysotile Institute maintains that “there is no evidence of increased cancer risk” if worker exposure to chrysotile is less than 1 fibre/cm3; an assertion denied by health experts. “WHO’s position is very, very clear”, says Maria Neira, director of public health and environment at WHO, “all types of asbestos are carcinogenic”. The organisation’s guidelines state: “increased cancer risks have been observed in populations exposed to very low levels.”

All of which has prompted more than 40 countries—including all member states of the European Union—to ban chrysotile. The World Bank has determined not to use it in any new development projects; and WHO has noted that “the most efficient way to eliminate asbestos-related disease is to stop using all types of asbestos”.

Nevertheless, about 125 million people across the globe are exposed to chrysotile in their working environment. Worldwide production remains at roughly the same level as in 1960: nearly 2·2 million metric tonnes per year. Vast development projects in Asia are largely responsible for maintaining the market. In particular, India’s asbestos industry is burgeoning.

From 2000—07, India’s use of asbestos rose from roughly 125 000 metric tonnes to about 300 000. Nearly all of India’s asbestos is mixed with cement to form roofing sheets. Bolstered by asbestos import tariffs that have been reduced from 78% in the mid-1990s to 15% by 2004, the country’s asbestos-cement industry is increasing by roughly 10% every year, employing in excess of 100 000 people. Since 2003, companies no longer require a special licence to import chrysotile.

Since 1960, India has incorporated about 7 million tonnes of asbestos into its buildings. The health consequences are already apparent, but the scale of the problem is not clear. “The Government of India has a very poor, almost non-existent, system to record death and disease”, explains Arthur Frank from Drexel University, Philadelphia, PA, USA. Besides, cancer is not a notifiable disease. Frank cites a hospital in Mumbai which sees a dozen cases of mesothelioma every year. Studies have shown high rates of asbestosis among workers in the industry, including in those whose exposure to the material has spanned less than 5 years. “But I suspect that there has been no real assessment of [asbestos-related disease] to the point that you can get accurate figures”, Frank concedes.

It is not simply a case of data collection. Of India’s 300 or so medical schools, only one has a training programme in occupational health. 55 million Indians are covered under the Employee State Insurance Corporation. “They have 6500 physicians”, points out Frank, “yet virtually none of them have had training in occupational health”. Consequently, asbestosis is frequently misdiagnosed as tuberculosis or bronchitis. Besides, “doctors do not have access to the standard ILO [International Labour Office] radiological plate which is needed to diagnose asbestosis”, V Murlidhar from the Occupational Health and Safety Centre, Mumbai, India, told The Lancet.

Asbestos-cement is durable, fireproof, and easily secured, unlike thatched roofs. It does not clatter in the monsoon or rust, unlike metal roofs; and it will not gust in the wind, unlike a sheet of tarpaulin. Its proponents claim it is vital for sustainable development. Alternatives such as polyvinyl chloride and ductile iron might have to be imported, whereas most countries have access to cement. But, says Frank, “there are many substitutes for asbestos which don’t carry the same health risk”.

The Chrysotile Institute claims that chrysotile can be used safely as long as employers follow basic precautions. This is just not feasible, answers Pat Martin, Canadian member of parliament and former asbestos miner. “If we in the developed world haven’t found a way to handle chrysotile safely, how can we expect them to do so in developing nations?” he asks.

Vessels laden with asbestos are deposited in Indian ports, to be dismantled by some of the country’s 60 000 or so ship breakers. For these individuals, and for most workers in the asbestos-cement industry, the outlook seems bleak. “Most workers are not protected at all”, notes Madhumita Dutta from Ban Asbestos Network of India based in Chennai. “Health and safety standards in the asbestos industry in India are negligible”, agrees Martin, he talks of factories covered in carcinogenic dust and workers using bits of cloth as rudimentary masks. “There is very low awareness of the adverse effects of asbestos amongst workers”, adds Dutta. Many Indians smoke, a factor which massively increases the risk of lung cancer when taken in combination with exposure to asbestos.

The difficulties do not end there. Intact, asbestos-cement locks in harmful fibres. But it does not always remain intact. Indian consumers are unlikely to know that as asbestos-cement erodes and crumbles, dangerous fibres are released; that you must never use power saws on asbestos-cement, nor cut the product dry.

“Every time you put a piece of asbestos-cement in place, you’re putting in place the seeds of a potential future problem”, Frank stated. Even if building materials are kept in pristine condition and future generations are made aware of the building’s contents, there is no legislation for man-made disasters. The 2001 Gujarat earthquake destroyed almost 400 000 homes. In the USA, after the World Trade Centre collapsed, some dust samples showed asbestos concentrations of 4%.

Hopes for India’s immediate future are muted. “We can expect a lot more death and disease, that’s no secret”, Frank told The Lancet. “There is no champion for the working person, or for the elimination or reduction in the use of asbestos, that I can see in the central Indian Government”, he added. Dutta points out that several parliamentarians have major holdings in asbestos companies, and there are asbestos manufacturing plants in state ownership. “The asbestos industry in India is a very powerful force”, agrees Barry Castleman, an environmental consultant who has advised the World Bank and WHO on asbestos. Both he and Frank asserted that the industry has even affected government agency studies into asbestos, providing funding and helping to design questionnaires.

At a minimum, those workers who are already ill must be compensated, says Murlidhar. As things stand only a handful have received compensation—India’s intricate labour laws make it difficult to hold negligent employers to account. The final aim, however distant, is an outright ban. “The health hazards of asbestos don’t warrant its use”, Martin says simply.

Talha Burki

Health advocates for the poverty-stricken Mississippi Delta in southern USA have spent millions of dollars over the years attempting to address seemingly intractable health issues disproportionately affecting the region’s African-American population. Now a group is turning to an unlikely source for a model of primary care provision: the health house programme of rural Iran.

Established in the early 1980s, the model uses community health workers to track villagers’ health, and provide basic care and health education. Trusted workers chosen from the community help patients connect with appropriate high-level services when needed. The programme has bolstered the health status of Iran’s rural population and garnered high praise internationally.

Continuous monitoring and support, and a community-based link to the fragmented US health-care system is just what the Delta needs as well, say health house advocates. The present system has failed the rural region for decades. Saddled with a long history of discrimination and unemployment, more than 20% of the population is uninsured, and rates of diabetes, hypertension, obesity, and infant mortality are among the highest in the country. Many residents have no access to regular care and turn to the hospital emergency room when they need attention.

Aaron Shirley is a long-time champion of health care for the Delta and chair of the Jackson Medical Mall Foundation, supporting a facility that attends to Mississippi’s underserved population. He is leader of the health houses initiative. Critical to its success, he said, is community involvement in both designing the programme and implementing it. “You’ve got to know the Mississippi Delta. There’s a distrust factor. But this [programme] is from the ground up”, says Shirley. “You’d be surprised at the response that we’re getting starting with the people and saying ‘here’s an idea, what do you think about it’ rather than going in and saying ‘here’s what we’re going to do’”, he added. “They’ve had a lot of that.”

Delta health houses, like those in Iran, will employ members of the community to serve as health workers. They will bridge the divide between public health and clinical medicine, tracking individual household’s health status and serving as advocates to improve living conditions including water quality and access to healthy food. They will help patients to negotiate the complex medical system, and follow physician instructions. The group initially will train workers with at least a high school education using the equivalent of nursing assistant certification, but hopes to develop an expanded curriculum with increased focus on community issues and even disaster preparedness.

Shirley and others are seeking US$30 million to begin supporting up to 15 health houses in the Delta region. With tight budgets in Washington, and reticence to adopt a model from a country in extreme disfavour in the USA, funding is an uphill battle. But the group is moving ahead with a pilot project in a donated building in Greenwood, MS. In addition to serving as a headquarters for the health workers, James Miller, another advocate for the project and managing director of Oxford International Development Group in Oxford, MS, says the building will be a meeting place for healthy activities, and will house exercise equipment and blood pressure monitors.

With health reform faltering in Congress, provision of community-based primary care for underserved populations will be paramount in the USA, both to improve access and cut costs. The use of community health workers like those in the Delta project, long a staple in global health programmes, is becoming more widely recognised and supported in the USA. According to Carl Rush, a community health expert based in San Antonio, TX, more states, insurers, hospitals, and the federal government are realising the value of the workers. They enhance disease prevention, ensure adequate prenatal care to prevent low birthweights, and encourage patient follow-up to reduce hospital readmissions.

Advocates hope turning to Iran as an unlikely ally in the promotion of rural primary health will finally start to meet the needs of the Delta population. “This is a human disaster that’s been hitting here for decades”, says Miller.

Nellie Bristol

India, the leading supplier of low-cost generic drugs to Africa, has begun fighting back to counter the confusion surrounding counterfeit drugs in the region. A raft of new and proposed anti-counterfeit laws could potentially deprive Africa of affordable, essential medicines.

The immediate cause of concern is Kenya’s Anti-Counterfeit Act 2008, which came into effect in July, 2009. The new law, which ostensibly seeks to clamp down on fake products, blurs the distinctions between generic, substandard, and counterfeit drugs, argue critics, including Médecins Sans Frontières (MSF). MSF depends mostly on low-cost generic versions of essential medicines to treat patients around the world.

“The definition of counterfeits in Section 2 of the new Kenyan law (Anti-Counterfeit Act, 2008) can be interpreted to refer to generics as counterfeits as they are considered to be substantially similar goods”, Allan Maleche, a lawyer and member of Kenya Ethical Legal Network on HIV and AIDS told The Lancet.

Kenya’s new law could become a template for other countries in east Africa. The draft east African policy on anti-counterfeits and anti-piracy has provisions similar to the Kenyan legislation with regard to generics; Uganda has a draft Anti-Counterfeit Goods Bill; and Tanzania, Rwanda, and Burundi are discussing these issues.

India has asked Kenya to make changes to its anti-counterfeit law passed last year that could make generic drugs exported by Indian companies into the country illegal.

In addition to sustained dialogue with Africa’s health ministers and other officials, India’s riposte, over the next few months, will include advertisements in the African mass media and interactive meetings with journalists and industry in several African countries to counter the confusion about generic drugs, said Padmanabhuni Venkata Appaji, executive director of Pharmexcil, a body set up by India’s Commerce Ministry.

The developments in east Africa are occurring against a worrying backdrop. Amar Lulla, joint managing director of Indian drug company Cipla, sees the recent anti-counterfeit initiatives in Africa as part of a campaign inspired by an embattled big pharma fighting to preserve market share for brand name drugs. Cipla is one of the world’s largest producers of generic medicines.

“There have been attempts in recent times to stretch the meaning of counterfeits at the local and global level”, said intellectual property lawyer Peter Munyi, partner in the law firm Sisule Munyi Kilonzo and Associates based in Nairobi.

However, despite the disturbing trends, all is not bleak. Besides continuing to publicly question whether the purported aim of tackling the problem of bad quality and substandard products, including medicines, can be achieved using intellectual property based laws and policies, African activists and lawyers are taking their battle to the courtroom.

A petition has been filed in Kenya by three people living with HIV/AIDS challenging the constitutionality of the anti-counterfeit legislation. The three petitioners want the Court to declare the anti-counterfeit law unconstitutional on the grounds that it will deny them access to affordable life-saving generic medicines and therefore rob them of their right to life. However, “at this point it is not clear when the suit will come up for hearing”, Munyi told The Lancet.

In the current scenario, a Ugandan model holds out hope for other African nations, said Cipla’s Lulla. The Ugandan model refers to Quality Chemicals Industries (QCIL), a Ugandan pharmaceutical company that has just started producing much-needed drugs to treat HIV/AIDS and malaria—Africa’s two biggest killers. The factory is now in advanced preparatory stages for WHO pre-qualification. “Cipla has been involved with the QCIL venture from the start, providing technological know how and expertise. We have been educating Ugandan health officials, sensitising public opinion in Uganda about the differences between substandard, counterfeit and spurious drugs. We are also in touch with international NGOs [non-governmental organisations], such as Oxfam and MSF, who are fighting for access to quality medicines at good prices”, says Lulla.

Patralekha Chatterjee

Following his long history of clashes with the pharmaceutical industry, the head of the German institute which assesses the cost-effectiveness of drugs and treatments will be forced to step down.

The Institute for Quality and Efficiency in Health Care (IQWiG) has been mentioned repeatedly in recent German press reports concerning the expenses of its controversial director, Peter Sawicki (panel). Now the IQWiG supervisory board has told 52-year-old Sawicki that his contract will not be extended after August, 2010.

Panel: Events in 2010 leading up to Sawicki’s dismissal

Jan 11 An open letter, signed by 600 doctors, is sent by Bremen-based general practitioner, Gunther Egidi, to the minister for health, calling for Sawicki to be kept on as the Institute for Quality and Efficiency in Health Care’s (IQWiG) director.

Jan 14 The managing director of the German Association of Research-based Pharmaceutical Companies, Cornelia Yzer, issues a press statement saying that the group would not comment on Sawicki personally, but that IQWiG’s methods do not conform to international standards.

Jan 19 German newspaper Handelsblatt publishes a report of an inquiry into Sawicki’s expenses, which allegedly show he made illegitimate claims worth more than €1100. Sawicki’s supporters claim that the report had been leaked in order to prompt his dismissal from IQWiG.

Cologne-based IQWiG was founded in 2004 and compiles reports for the Federal Ministry of Health and the Federal Joint Committee (G-BA). The G-BA then uses this information to decide which drugs public insurance funds will cover. The institute was designed to operate as an independent watchdog with a similar role as UK’s National Institute for Health and Clinical Excellence. But IQWiG’s ability to function apolitically was called into question when newspaper reports in November, 2009, referred to a white paper leaked to health policy makers, calling for Sawicki to be replaced.

Speaking to The Lancet, Gerd Antes, director of the non-profit German Cochrane Centre, which produces evidence about the effects of health-care interventions, says this is a politically motivated move designed to weaken the IQWiG. “They know Sawicki is a hardliner and that with him as head, industry and the politicians who support it know they cannot force their products into the market as easily and quickly—and they want that to change.”

“In principle industry is complaining that innovation in terms of medical products is inhibited, because they can’t just push things into the market. But you have to remember that without strict regulations and a control mechanism, people might take these products and suffer later.”

Over the years, Sawicki has often been engaged in heated wrangling with the German Association of Research-based Pharmaceutical Companies (VFA), which he has often urged to hand over various unpublished studies. Made up of 46 companies and more than 100 subsidiaries and affiliated companies, the VFA employs almost 90 000 people in Germany and accounts for more than two-thirds of the country’s pharmaceutical market. But although it has attempted in the past to submit unpublished commercial-in-confidence documents to IQWiG, Sawicki has insisted that the concept of such data contradicts the principle of transparency. By refusing to hand over all data requested or push for some documents to remain confidential, Antes says the VFA is simply not playing fairly. “Essentially, the aim of the organisation is to weaken the barrier to get potentially not very effective products into the market, so to reduce the control mechanism in place which is acting as a filter.

“All of this is what the big picture is about, namely IQWiG rightly asking for information and elements of the pharmaceutical industry deciding they might deliver the parts they like—they want to include studies favourable to them. They are not sticking to the rules.”

In 2009, IQWiG and the VFA seemed to have achieved the impossible by agreeing on how to manage unpublished pharmaceutical industry studies. In the past, IQWiG had refused point blank to officially accept any of the VFAs commercial-in-confidence documents. Under terms of the new deal, however, the VFA would submit these unpublished studies to IQWiG, which would then publish a summary of the methods and results involved. Any confidential details supplied by pharmaceutical companies at a later date, however, would remain protected and IQWiG would pledge not to publish them.

Despite this agreement, IQWiG’s methods still seems to be a bone of contention for the VFA. Speaking to The Lancet, Sawicki said IQWiG’s methods are high quality and the institute is open to constructive criticism. “Our methods are developed in cooperation with our Scientific Advisory Board. There is the possibility of posing a public statement relating to our scientific procedures.”

“In the case where our recommendations do not suit the pharmaceutical industry, they like to admonish that our methods are not correct. However, it is never specified what exactly is wrong with our procedures and how alternatives would improve our results.”

VFA communications director, Susan Knoll, says IQWiG’s methods can still be criticised in terms of it not complying with international standards. As an example, she outlined the use of a scoping process, whereby every stakeholder from doctors to scientists, researchers to patients, and health insurance providers are all brought to the table to decide what their objectives are and how they will be achieved.

According to Knoll, one of the most striking examples of how IQWiG was, according to the VFA, not using sound methods, involved the German Hypertension Society (DHL) last year. “The DHL very clearly opposed IQWiG and criticised the assumption it was making about patients and their proposed treatment. For IQWiG, there was just this ‘ideal patient’ who suffered from high blood pressure and that was it, and who otherwise was basically thin, healthy, and generally fine. This however, simply isn’t true and the case is, as the DHL readily confirmed, that very many, indeed most, high blood pressure patients have, or are developing, other conditions which need to be considered such as diabetes. It seems the intention of avoiding these facts was mainly to focus on reducing costs and not on whether the drug was really useful or not.”

Not all, however, have been critical of IQWiG’s methods. Jos Kleijnen runs Kleijnen Systematic Reviews, which prepares systematic reviews and health technology assessments of interventions. These are then used to support policy making, licensing, and reimbursement. Kleijnen has worked closely with both the VFA and IQWiG in the past. He says both parties could improve in different ways. Speaking to The Lancet, he said that IQWiG’s methods are extremely high quality. “Based on our extensive history in preparing systematic reviews and health technology assessments at many levels, I think I can say with some authority that IQWiG’s methods are of the highest world standards—they provide very systematic, very reputable data.”

“We did, however, obviously have some problems, but these were not with the methods—the scientific means of evaluating treatment—but with the procedures it operates, for example, the lack of independent experts, or the fact that, ultimately, what ended up being produced after all the reviewing was an IQWiG product.”

Though recognising these areas where IQWiG could improve its procedures in compiling reports, Kleijnen was eager to also point out that the reports produced by the pharmaceutical industry are also not without fault. “They sometimes compare their product with a placebo instead of current rival products, or they fail to research outcomes. For example, a product may well be proven to lower blood pressure, but there is no information on whether or not it increases the rate of heart attacks and mortality.”

With the decision now having been officially taken by the IQWiG board, there is little left for Sawicki now other than to finish his directorship well. Speaking to The Lancet, Sawicki said he “very much regretted” not being able to continue his work after August, 2010, but says he should not continue to be viewed as an industry opponent. “I have always been open and have honestly voiced my thoughts and this is apparently labelled with the phrase ‘hardliner’. I am by no means against the pharmaceutical industry but I am certainly for a better and more trustworthy pharmaceutical industry.

“I want the pharmaceutical industry to produce progressive reports and not copies of old products which are already on the market. I want them to carry out relevant studies, not only for the approval of a certain drug but much rather for the assessment of patient relevant benefit aspects—and these reports should not be manipulated or biased in any way. I would like all study results to be published in their entirety, regardless of their outcome.”

Rob Hyde

As news crews begin to head for the exits, and Haiti coverage recedes from the front page, the situation on the ground remains extremely dire. 3 weeks after the 7·0-magnitude earthquake that devastated Port-au-Prince and surrounding areas, the official death toll is 212 000 and as many as 700 000 people might have sustained traumatic injuries, according to the Haitian Government.

So far, tens of thousands of those survivors have been treated in mobile clinics, field hospitals, and inflatable buildings by aid groups like Partners in Health, the International Committee of the Red Cross/Red Crescent, and Médecins Sans Frontières (MSF). The latter alone has treated roughly 7000 patients and done nearly 1000 surgical operations in some 17 sites throughout the affected area. “The first phase of emergency surgery is more or less over”, said Renzo Fricke, the MSF emergency coordinator in Port-au-Prince. “Now we’re transitioning to the second phase of post-operative care and rehabilitation, and that brings its own set of challenges.” Fricke compared Haiti’s health situation to an amputation: “The operation itself can be done in a couple of hours, but it requires long-term management.” It is an apt analogy; the disaster’s defining injury, amputations could leave some 200 000 Haitians without at least one of their limbs, many surgeons say.

While aid and personnel continue to pour into the country, it is unclear how the present level of care will be sustained. “Lots of field hospitals are working with the Comfort”, said Fricke, referring to the US Navy hospital anchored a mile off of Port-au-Prince, where, as of Jan 28, nearly 500 critical cases had been transferred by helicopter. “But the ship won’t be there forever. We have to be committed to the long term—to strengthening Haiti’s health-care system.”

Of the dozens of hospitals and clinics in Port-au-Prince before the earthquake, only eight remain standing. The rest, including all three MSF facilities and the AIDS clinic Gheskio, which oversees more than half of Haiti’s AIDS patients, lie in rubble. The main hospital in Leogane, the epicentre of the earthquake, collapsed as well, whereas overwhelmed hospitals in Jacmel, 40 km to the south, are running out of drugs. “We’re out of chloroquine and we don’t have anything left for gastrointestinal infections”, said Lisa Johnson, an American pharmacist volunteering at Hospital Emmanuel on the outskirts of Jacmel. “Because of the poor water and sanitation, GI [gastrointestinal] infections make up about 60% of our cases.”

“Our first priority is to restore access to care”, said Dana van Alphen, director of a 12-member WHO team charged with coordinating the many disparate relief efforts underway. In collaboration with the ministry of health, WHO has begun drafting a long-term strategic plan that incorporates the work of some 160 organisations on the ground. “Coordination is a major challenge”, van Alphen said. “We have to work together to strengthen hospitals in rural areas.” Asked how long the team would be in Haiti, she could not say: “I don’t know. I don’t think anybody knows.”

In addition to secondary infections, communicable diseases threaten to ravage displaced communities. The government estimates that more than 1 million Haitians have been made homeless by the earthquake. Although there have been no documented outbreaks to date, medical teams in Leogane have reported a growing case load of diarrhoea and tetanus. In Jacmel, several suspected cases of measles prompted the recent vaccination of children in the city’s largest refugee site. And, on Feb 2, UNICEF, in collaboration with the ministry of health and WHO, launched a vaccination campaign against diphtheria, tetanus, and measles aimed at covering the entire quake-affected area.

Still, despite the high-level strategising and the throngs of medical workers arriving every day, Haiti’s devastation has rendered even the most basic tasks substanital obstacles to progress. At a recent UN health cluster meeting in Jacmel, the director of the Haitian Red Cross, Madame Germaine, explained that she could not store the measles vaccine overnight; the Red Cross building was too damaged to enter. “Does anyone else have a refrigerator?” she asked. No one raised a hand.

Patrick Adams

In 1948, the formation of the UK’s National Health Service (NHS) promised free health care for all, however, prisoners were excluded. Despite decades of grave concern and reports about inferior health care for prisoners, it took nearly half a century for prison health to finally be integrated with the NHS.

By April, 2006, the NHS had taken over all budgetary, policy making, and policy implementation responsibilities for prison health, and a formal partnership between the NHS and the prison service to provide health care for all prisoners was born. However, over the past few years, there has been increasing concern about the quality, and continuity, of health care that the average offender receives both in and out of prison. Health care for offenders is not currently equivalent to the health care that everyone else in the country is receiving, and with offenders representing some of the most damaged and weakest people in our society, both in a social and medical capacity, it was clear that changes needed to be made.

In November, 2009, the Department of Health launched the first comprehensive strategy of health care that included offenders. “For many, the criminal justice system leads to their first contact with health and social care professionals—whose contribution is so vital to addressing their needs. The link between offending, reoffending and wider factors, including health, is widely recognised”, states Phil Hope in the introduction of the report on the new strategy.

With many prisoners in the UK serving very short sentences, sometimes even only months, this new strategy takes into account the whole pathway of an offender, both inside and outside of prison. “They [prisoners] bring their health problems from the community into the prison, and they will take them back into the community after they have completed their sentence”, says Andrew Coyle, professor of Prison Studies at the School of Law, King’s College London.

Richard Bradshaw, director and head of offender health at the Department of Health, thinks the new approach is a positive step and notes that the partnership between the prison service and the NHS has already been a successful one. “Over the last decade we have made huge progress [in prisons]…yet looking out to the wider criminal justice system, it is clear that much more is needed if we are to even begin to address the array of complex, multiple needs evident in this population—requiring active partnership working across a range of health, criminal, and social care agencies.”

“In brief, the delivery plan sets out to improve outcomes by identifying a person’s health and social care needs as early as possible on their offender pathway—not only for the individual, but also for society in terms of reducing health inequalities and reoffending and improving public protection”, says Bradshaw.

The new strategy was mainly a response to Lord Bradley’s April, 2009, review of mental health issues and learning disabilities within the criminal justice system. In his review, Bradley reports that “there are now more people with mental health problems in prison than ever before. While public protection remains the priority…custody can exacerbate mental ill health, heighten vulnerability and increase the risk of self-harm and suicide”.

Graham Durcan, associate director at the Sainsbury Centre for Mental Health, praises the work that has already been done by the NHS for mental health care for prisoners. “There is no question that prison mental health care has improved since the expansion of mental health inreach teams and the shift of responsibility for health care by the NHS, but we were starting from a very low base. The level and type of need was probably not really understood until inreach teams went into prisons”, says Durcan.

There is some concern, however, that the goals laid out in the new strategy might be too ambitious, particularly amid the current financial climate. Charlie Brooker, a professor of mental health and criminal justice at the University of Lincoln is not convinced. Brooker is doubtful that appropriate investment will be made to implement the Bradley report and points to the unsuccessful implementation of recommendations from the Reed Report of 1992 about offenders with mental disorders: “The Bradley report will end up like the Reed Review in the early 1990s—a useful report strangled at birth by [the] lack of resources.” A 2008 report about spending on prison mental health care for the Sainsbury Centre for Mental Health, co-authored by Brooker, states that in 2007 £20·8 million was spent on mental health care in prisons through inreach teams, that is, “over £300 for each member of the prison population”. However, this report goes on to say that this amount will have to be trebled to make services for people in prison equal to those in the wider community. “For too long we have seen too many people with mental health problems in custody, at high cost to the taxpayer, to their health and to their communities…It is now more vital than ever that public money is spent wisely on services that make a difference”, said the Sainsbury Centre in a statement issued in response to the new offender health-care strategy.

Marcus Bicknell from the Royal College of General Practitioners (RCGP) welcomes the new strategy and notes the importance of emphasis on the mental health of offenders but does not want physical health care for offenders to fall by the wayside. “The strategy seems to have a very strong mental health emphasis, following on from the Bradley report, whilst I’m happy to accept that the mental wellbeing of offenders is very important, it is also very important that we do not ignore how important their physical health care is.”

Bicknell does, however, welcome the increased focus on training in the new strategy, and he points out that specialised training for health professionals who work in secure environments has historically been “pretty narrow”.

The new strategy also includes piloting general practitioner (GP) registration of some prisoners with a prison GP. Currently, “those who receive a sentence of 2 years or more are de-registered from their community GP entirely and their records stored by their local NHS until their release”, explains Bradshaw.

At present, continuity of care for offenders while in and out of prison is difficult. “The medical records from the community do not follow the patient into prison with them, so it can be quite difficult to access those records to find out what has happened in the patients’ previous medical history”, says Bradshaw. Bicknell also remarks that computerisation of prison health-care centres has been slow, “but this is a work in progress”, he notes, and every prison health-care centre will hopefully have computerised medical records by the end of 2010. Bicknell thinks the pilot of registering prisoners with a GP while in prison will be useful but he is doubtful about its effect on the quality of health care for offenders; “I am not convinced that it would make an enormous difference in the health care that they receive.” Bicknell is also apprehensive about offenders being able to register with a GP in the community after they leave prison. “There are advantages to registering patients when they are in prison but I do not think anyone has really piloted, or addressed, the issues of what happens on [prisoners'] release, and continuity [of health care] is clearly important.” Bicknell also points out that despite computerisation of prison health-care centres there will still be no links to medical records between the community and health-care centres in prisons, “there are huge issues about connecting to the national medical records, and for prisons there are huge issues about security as well”.

Some people are concerned about the lack of inclusion of certain groups of people within the strategy. The Sainsbury Centre noted that the new strategy did not mention any specific needs for people from black and minority ethnic communities.

Dawn Edge, a researcher at the school of Nursing, Midwifery and Social Work at the University of Manchester, also welcomes the new strategy but is concerned about the lack of mention of specific health-care plans for female offenders. “Although research suggests that prisons could actually be very useful in terms of improving the health of women prisoners—eg, screening, health education, etc—the extent to which this happens is patchy at best. This may be because prisons are designed primarily for men and their focus is on security. Womens’ health needs are therefore easily over looked. What must not be forgotten is that this has massive implications for society—not least because the majority of women in prison are mothers/mothers-to-be. Their incarceration has serious and almost always negative consequences for their children who, in turn, become more likely to enter the criminal justice and/or mental health systems.”

Many experts are also concerned about the amount of integration that is needed among different sectors. “Ultimately, however, it is for the courts to decide whether an offender receives a mental health disposal, a criminal justice disposal, or both”, says Bradshaw.

The Sainsbury Centre commented on the need for accountability, particularly as questions about mental health in offenders were raised in the early 1990s with the Reed Review. “We have been talking about national coverage of liaison and diversion services since the Reed Report in 1992. The case for action is clear. What we need now is a clear line of accountability for making it happen. The time to act is now.”

Nayanah Siva

13-year-old Seema lives with her grandmother Susheela and three other orphaned cousins, in a dark, poorly ventilated two-room tenement in a slum in Bangalore, the capital city of Karnataka state, southern India. She has lost her parents to AIDS, is HIV-positive, visibly malnourished, and has cataracts in both eyes. Seema is not yet on antiretroviral therapy (ART) as she has a healthy CD4 cell count, but she often becomes ill with fevers and body pain, which her grandmother attributes to the “worms” that she has in her blood.

Susheela, who is the sole guardian of the children, has asthma and a heart ailment. She was running a small business selling short-eats from a pavement stall until recently, but is too ill to work now and has no income. The family has no access to support other than some food items provided to them once a month by Milana, a family support group for HIV-positive people based in Bangalore.

Seema is just one of the indeterminate numbers of children that have been orphaned by HIV/AIDS in India. Stories similar to hers are being played out in thousands of homes across India and in Karnataka. But India’s response to caring for these children remains wanting, say campaigners.

3 years into National AIDS Control Programme Phase III (2006—11), which places special focus on medical treatment and after care, access to schooling, and adequate nutrition, government interventions for AIDS orphans are conspicuous by their absence in any area other than paediatric ART.

While estimates for children orphaned by AIDS are unavailable there is evidence that 3·8% (nearly 100 000) of an estimated 2·5 million people living with HIV/AIDS in India are children. UNICEF estimates that there could be about 4 million affected children in India, located mostly in the high HIV-burden states of south and northeast India (affected children include those living with HIV or those who are orphaned by AIDS, and children whose parents are living with HIV).

Jyothi Kiran, founder of Milana, which gives comprehensive support to roughly 300 children affected by HIV says, “children are the worst affected by the problems that HIV brings with it. They suffer severe stigma and neglect and are very often abandoned. Orphaned children are denied even basic necessities like food and nutrition by their extended families. If they are themselves HIV-positive, the situation becomes worse and their very existence is threatened”.

If they have ailing parents, children are likely to be withdrawn from school to care for them or to go out and earn. 10-year-old Anand is HIV-positive and has lost his father to AIDS. His father was the only working member of the family and after his death they have no income. His mother is HIV-positive too and unable to work. Anand and his mother live in rented premises, from which they expect to be evicted soon because they have not paid the rent for over 6 months. He has been withdrawn from school as Anand’s mother cannot afford his school fees. He often goes to the ART centre alone for his monthly medication and there are occasions when he has missed appointments because his mother cannot afford the bus fare.

India has a duty to care for children like Anand, especially since it is a signatory to several international conventions and declarations on children and HIV/AIDS. The Government of India acceded to the UN Convention on the Rights of the Child (CRC) including protection against HIV/AIDS in 1992. Further, at the UN General Assembly Special Session on HIV/AIDS in 2001, India pledged to protect children affected by the epidemic. In June, 2006, the UN General Assembly adopted the Political Declaration on HIV/AIDS, which reiterated government commitment to “addressing as a priority the vulnerabilities faced by children affected by and living with HIV; providing support and rehabilitation to these children and their families, women and the elderly, particularly in their role as caregivers; promoting child-oriented HIV/AIDS policies and programmes and increased protection for children orphaned and affected by HIV/AIDS;…and building, where needed, and supporting the social security systems that protect them”.

Following on from this declaration, in July, 2007, the Ministry of Women and Child Development and National AIDS Control Organization released the Policy Framework for Children and AIDS. This policy acknowledges the need to realise the basic rights for all children as under the UN CRC for children affected by HIV/AIDS and has a goal of reaching 80% of the children most in need by 2010.

2 years after the policy framework was released, it exists largely on paper, and children continue to be deprived of most of their rights. Suresh Shastri, regional coordinator, Karnataka state AIDS Prevention Society, says: “We have achieved a degree of success with testing and access to treatment, but there are still gaps in other areas such as education, nutrition, etc, and we are working on plans to address them.”

At the beginning of 2009, the Department of Women and Child Development, Government of Karnataka, allocated a yearly budget of Rs 1 crore (US$200 000) specifically for the needs of affected children. But 10 months later, the budget remains unspent. Narmada Anand, deputy director of the department, rationalises the delay, “we are in the process of determining how best this money can benefit affected children. It is important to put systems into place and governmental procedures cannot be hastened”.

Christy Abraham, theme leader for HIV and AIDS for Action Aid India, says: “The situation points to apathy on the part of the state. The excuse is that there is no knowledge on the number of children who need help and where these children are. Is the state not capable of developing a system for identifying the children most in need and providing them protection?”

This situation means that it is mainly non-governmental organisations and HIV-positive network groups that are working to reduce the effect of HIV/AIDS on children in India. They provide nutrition supplements, referrals to testing and treatment facilities, treatment for opportunistic infections, education support, and linkages with existing government child welfare schemes for children who need them.

“We are able to reach only a fraction of those in need of help. The value of our interventions, however, lies in the fact that we have established the difference that comprehensive support can make to the lives of affected children”, says Lloyd Troy Cunningham, care and support specialist for orphaned and vulnerable children at Engender Health, an organisation that works with these children in Karnataka.

Ivonne Camaroni, chief of UNICEF’s HIV programme in India points out, “As a nodal ministry, MWCD [Ministry of Women and Child Development] is in a strategic position to ensure access to basic services for affected children in collaboration with other concerned departments, especially through its two flagship programmes Integrated Child Development Scheme and Integrated Child Protection Scheme.”

But campaigners are worried about the amount of time that it will take to get plans and programmes specifically for children orphaned by HIV/AIDS off the ground. They fear that in bureaucratic India, the government will have to wade through yards of red-tape before putting systems into place.

The National Commission for Protection of Child Rights, in collaboration with Action Aid, held a public hearing in December, 2009, to draw attention to the plight of children affected by HIV/AIDS in India. Shanta Sinha, chairperson of the commission, presiding over the public hearing pointed out that there was a wide gap between policy formulation and the plight of children. She said: “Government and non-government organisations should put their heads together to fill up these gaps. We need to evolve specific solutions without waiting for larger policy initiatives.”

The names of all children and their relatives have been changed to protect their identities.

Bharathi Ghanashyam

1 year after US President Barack Obama kicked off his drive to reform America’s US$2·7 trillion health system, his strategy has been derailed—at least for now.

On Jan 19, Massachusetts elected a new senator, Scott Brown, a Republican who opposes the Democrats’ health strategy to improve care for tens of millions of people while cutting costs. Up until Brown’s election, Obama’s reform laws were expected to win Congressional support with an ultra-narrow majority hinging on one Senate vote. But with Brown’s election, Obama has likely lost his chance at the Congressional majority needed to quickly enact his suite of reforms.

The implications for American physicians and patients are debatable. But for US health researchers, Obama’s quandary represents a clear setback. Through the proposed legislation, the US Government was poised to give comparative effectiveness research (CER)—the research area in which competing medical therapies are tested against each other to compare their benefits to patients—powerful traction in driving down costs while improving national health outcomes.

The day after Brown’s election, Obama promised to continue the fight: “We know that we need insurance reform, that the health insurance companies are taking advantage of people”, he told the ABC television network. “We know that we have to have some form of cost containment, because if we don’t, then our budgets are going to blow up.”

Obama’s cost containment strategy has increasingly been structured around bolstering CER since he first plunged into health-care reform efforts. Last June, the President persuaded Congress to earmark $1·1-billion for new CER programmes. The now-jeopardised reform initiative aimed to add to that by devoting a further $600 million in yearly funding to a new CER clearinghouse—either placed within an existing federally funded research institution, such as the National Institutes of Health, or within an entirely new agency.

With a new CER entity in place and fuelled with lavish funding, the White House aimed to ensure that health-care purchasers such as private health management organisations or Medicare—the $440-billion public health system that serves US seniors—could “make hard-edged decisions about what they are willing to pay for”, explains Sean Tunis, who served as Medicare’s chief medical officer from 2000 to 2005, and now directs the Center for Medical Technology Policy in Baltimore, MD.

Tunis credits Peter Orszag, Obama’s director of the Office of Budget and Management and the former director of the Congressional Budget Office, for directing the White House and its allies in Congress to centrally integrate CER into the reform drive. “30% of US health services expenditures are seen to be of no clinical benefit”, says Tunis, “and CER is seen as a means to carve away at that 30%”.

Politicians are attracted to CER as a means to rein in industries (insurance, pharmaceuticals, medical devices) that extract profits from a national health system best known for delivering mediocre health outcomes—the US ranks behind at least 30 other countries for key health-care quality indicators including life expectancy and infant mortality, according to WHO.

The establishment of structures for comparative research, whether they are based on the Obama legislation now in jeopardy, or on already existing programmes, will be vital to future reform efforts, says Christopher Murray of the Institute for Health Metrics and Evaluation at the University of Washington in Seattle, WA.

“Whenever a country embarks on large-scale reform of its health-care system, comparative evaluations become crucial”, says Murray, who is a specialist on comparing health system reform strategies amongst several countries including the USA. “Built-in evaluations may be the missing ingredient that will allow us to finally reform health care in the United States. But I’m not sure the political discourse gets this message very clearly.”

CER might seem innocuous from a distance, says Tunis, but for many in the US health services industry, it represents a threat. “Vendors, clinicians, and patients all worry about decisions taken by third parties, especially in government.”

Drug and medical device manufacturers, along with professional associations such as the American Medical Association (AMA), soon learned that many drugs, technologies, and practices were not going to easily survive Medicare’s call for health outcome tests based on CER studies. The first big warning came from ALLHAT, a massive study of cardiovascular drugs that found several new and expensive hypertension control drugs to offer negligible advantages over older, cheaper drugs.

Thanks to ALLHAT, consumers, public drug plans, and private health insurance companies have saved huge amounts of money within the multibillion dollar antihypertensive drug market. On the other side of the ledger, however, the drug companies that make the newer drugs found to be no better than their older, cheaper, rivals have had losses in market share.

Even if President Obama’s reform efforts collapse and a new CER entity is not created, Tunis believes that Medicare’s current efforts to promote CER, assisted by the $1·1-billion already committed to CER by Congress last year, has forced US health-care providers to accept that CER “is here to stay”.

“There’s no going back. People in the research community have changed the way they think”, Tunis argues. “The life sciences industries have now gotten the message that studies that merely satisfy the FDA [Food and Drug Administration] are not good enough. The research community is aligning with what decision makers need from them.”

Even so CER has enemies, says Harry Selker, executive director of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center in Boston, MA. With Congress under pressure to place a generously financed new CER agency at the centre of its efforts to overhaul health care nationwide, CER has become the focus of an intense political lobbying effort which aims at restricting the scope of the proposed new federal CER agency. Lobbyists are also struggling to open access to the new CER agency’s decision-making processes for professional associations and corporations with business interests tied to treatment decisions based on CER findings.

“Although the value of funding CER is clear, many are unaware that embedded in the legislation are provisions giving substantial influence to the medical products industries that are interested in CER research outcomes”, Selker says. “The legislation mandates the creation of an entirely new private—public research entity that, due to industry lobbying, guarantees industry three seats on this entity’s 15-member governing board, as well as representation on its methodology committee.”

Selker also points to language in the Senate’s version of the legislation “requested by industry lobbyists” that threatens to withdraw federal funding from investigators who report on research funded by the proposed new CER agency that is not “within the bounds of and entirely consistent with the evidence”.

Determinations regarding such consistency, says Selker “would be made by the newly created research entity, which would have industry involvement both in its governance and in study design”. Allowing this legislative language to stand, Selker says “would be a retrograde step that would inhibit the conduct of CER and call its integrity into question”.

Alongside the industry lobbyists is the AMA—which represents 250 000 physicians. Shortly before it agreed to support the Senate’s version of the proposed legislation, the AMA strong-armed lawmakers into, in the words of AMA president-elect Cecil Wilson, “modifying provisions to establish an independent comparative effectiveness research entity to secure greater representation for physicians on its governing board and to clarify that this entity cannot issue practice guidelines or make coverage, payment or policy recommendations”.

Although the AMA supports CER, it does not want government to intrude into the patient-physician relationship, Wilson says. Nor does it want CER to be employed to justify health-care “rationing”.

The sight of the AMA aligned with industry interests to restrict the use of CER alarms observers such as Peter Lee, president of the Pacific Business Group on Health, a coalition of health-care purchasers pushing to improve health care while moderating costs. Lee has pulled together a counter-lobby demanding “free and open publishing of the research, with scientists allowed to say what they want based on their findings. From a patient and purchaser perspective it is critical to have no limits on use of research results”.

Lee says he views CER as a “fault-line issue” in the debate over health-care reform. “Changing towards payment based on performance is where health care is going in America and around the world”, he argues. “We have to get beyond performance-blind medicine. On one level, it’s laughable to argue that CER threatens to bring the evil bureaucracy into the patient-physician relationship”, says Lee. “But this is a litmus test for the overall reform effort.”

Paul Christopher Webster

Yemen is facing a growing humanitarian crisis due to the ongoing civil war between the government and Shia-Al Houthi rebels, in the northern governorate of Sa’ada.

Despite several attempts at peace, there have been six episodes of fighting since the beginning of the war in 2004, and the latest episode in August, 2009, has led to an additional displacement of several thousands of people. Irshad Shaikh, regional adviser for emergency preparedness and humanitarian action in WHO’s Regional Office for the Eastern Mediterranean Region (EMRO), said that these internally displaced people (IDP) have undergone repeated displacements, which “has led to exhaustion of their coping capacities due to loss of their livelihoods and assets”. Furthermore, as food, water, sanitation, shelter, and health-care needs have become extensive, he added, “the population is on the brink of disaster if the conflict is not stopped and a solution found”.

The UN High Commission for Refugees, currently estimates the number of IDPs to be 200 000, which mainly includes women and children. Aanchal Khurana, communications and advocacy officer, emergency preparedness and humanitarian action, WHO EMRO, said “catering for the increasing number of IDPs and their increasing health needs is becoming more challenging, whereby prolonged displacement with no end in sight is making them more vulnerable to poor health outcomes and outbreaks of communicable diseases”. Although no outbreaks have been reported per se, the risk remains high and the disease surveillance system for IDP needs to be strengthened.

The health problems encountered in the IDP are representative of diseases endemic in Yemen such as diarrhoeal diseases, malaria, respiratory tract infections, measles, meningitis, urinary infections, and skin infections (mainly scabies and rashes). Shaikh said that there has been an incremental increase in consultations for respiratory tract infections, malaria, and diarrhoeal diseases as more people are attending the mobile medical clinics that have been set up by WHO and the ministry of health in the IDP hosting governorate’s of Al Jawaf, Hajjah, and Amran, along with a fixed clinic in Al Mazrak camp in Hajjah. Ben Abdallah Kamal from UNICEF said that because of ongoing fighting, the Sa’ada governorate is inaccessible to humanitarian agencies.

The recent cold weather has further increased the incidence of respiratory chest infections and skin infections in internally displaced children in Sa’ada and Amran, where children make up more than 75% of the IDP population.

WHO, in collaboration with the ministry of health, is supporting the routine vaccination of displaced children, against measles, whooping cough, meningitis, tetanus, and diphtheria. Shaikh said that “the paradox of conflict is that when an otherwise inaccessible population in remote areas are forced out of their homes in its wake, they usually gather at service delivery points in search of food, water, and shelter. This presents an opportunity to vaccinate them, which would have otherwise not been feasible due to difficult or no access.” The measles campaign also distributed vitamin A supplements to IDP both within and outside the camps.

In response to the renewed conflict in August, 2009, the UN and the ministry of health established a health cluster approach to address the multidimensional nature of the crisis, with international and local non-governemental organisations and UN agencies being an integral part of the relief response. Most of the aid provided so far has been in secure and accessible areas and has included emergency education, food, health, shelter, water, sanitation, and hygiene. The health ministry is providing relief efforts or basic services to populations in Sa’ada.

Kamal said that “UNICEF is the lead cluster in water, sanitation, and hygiene promotion field interventions (WASH) in Al Mazrak camp and is providing life-saving assistance to conflict affected populations and surrounding governorates of Amran and Hajjah and the host communities”.

Yemen is one of the world’s most water-stressed countries, with only 50% of an estimated 6·6 million urban population having access to public water systems, and 40% of an estimated 17 million rural population receiving a piped water supply. The access to potable water is even lower for the conflict-affected areas.

The WASH programme included provision of chlorinated, reliable, and adequate potable water; improved storage facilities, distribution of hygiene kits and separate basins for jerry cans. It led to a substantial improvement in diarrhoeal diseases from 192 cases the first week to 105 in the fourth week. Each displaced person receives 20—30 litres per day, which is thought to be 100% coverage. Sanitation coverage also improved to almost 95% for 1200 families because UNICEF and OXFAM constructed 1150 latrines, installed 919 water filters, distributed chlorine tablets, installed 15 showers, and improved hand-washing facilities. 48 IDP volunteers were trained as hygiene promoters and as a result, water-related and sanitation-related diseases have greatly decreased in the general IDP community.

UNICEF is also cluster leader for nutrition and in early October carried out a rapid assessment in Al Mazrak camp “tent by tent”, said Kamal. This screening found that of a total of 1074 children aged 6 months to 5 years, there were 10·6% with severe acute malnutrition, 19·5%, with moderate acute malnutrition and 30% with global acute malnutrition. By Oct 9, 2009, UNICEF started an outpatient therapeutic care centre to manage the severe and moderate cases of malnutrition.

The IDP volunteers were also involved in screening children younger than 5 years for malnutrition, counselling mothers and families about appropriate nutrition and breastfeeding for children and babies, and following up of malnourished children managed by the outpatient centre. In early November, UNICEF launched inpatient care to target malnourished children with complications and in late November, the outpatient centre was handed to Médecins Sans Frontières, Spain, which is addressing malnutrition in Al Mazrak camp 1 and 2.

Yemen has one of the worst malnutrition rates in the world with 42% and 15% of children younger than 5 years being moderately to severely underweight and severely underweight, respectively, according to a recent UNICEF report. Child malnutrition is the underlying cause for around 60% of mortality in children younger than 5 years (73 per 1000 livebirths). Malnutrition is also related to the high incidence of low birthweight (32%), low rate of exclusive breastfeeding babies, and high incidence of diarrhoea (seven episodes per child each year).

Kamal indicated that there is no data for malnutrition in Sa’ada before the conflict but national data show that in children younger than 5 years, 42% are moderately to severely underweight, 15% severely underweight, and 12% have moderate to severe wasting, with stunting affecting half the population (53%). Around 48% of households are food insecure, and IDP is one of the most food insecure population groups in Yemen with Sa’ada and Hajjah having the highest food insecurity levels in the country. An interagency assessment done in September, 2008, in Sa’ada found 83% of adult IDP did not eat the entire day or were skipping meals daily, and most consumed small quantities of food of poor quality.

The plight of IDP is further compounded by the influx of refugees from surrounding countries such as Ethiopia, Iraq and Somalia, which “are overwhelming an already under-resourced system”, said Aanchal. Sheikh said that, as of last week, the World Food Programme stopped giving food to south-central Somalia because of increasing insecurity, which might mean more Somalis seek refuge in Yemen. The country is already host to nearly 200 000 refugees, mainly in the south, most of whom are Somalis.

The UN humanitarian response plan for Yemen is aimed to last from January to December, 2010, and is requesting US$177 428 417 to provide life-saving assistance to 1·4 million food insecure people, including 200 000 IDP and 162 362 refugees. In September, 2009, a flash appeal for $11·6 million was launched in response to the renewed conflict and, as of Nov 12, 2009, 50% was funded.

“The pre-existing poor health indicators in Yemen coupled with its vulnerability to natural disasters such as floods and drought, poverty, water scarcity, food insecurity, high population growth rate, severe malnutrition, conflict in the north and refugees in the south, and the recent problem of access and security of health-care providers and donor fatigue, presents the humanitarian community with many challenges for relief efforts”, said Aanchal.

May Meleigy