Hello from Kampala!

My name is Neil, and I am a second-year medical student at the Keck School of Medicine. I have been incredibly lucky to have the chance to travel to Uganda with a group of PHR leaders and other students. We're here to be part of the East African Health and Human Rights Conference, which is going to bring together health professional students from all over East Africa—Uganda, Burundi, Rwanda and Kenya. The issues that students face here are vastly different from the ones we face in the US, but the strategies we can employ to make changes are similar. The goal is to share experiences and make new friends whom we can help and support as we continue in our careers.

We touched down in Kampala on Sunday night. The cab driver took us straight to the guest house we are staying at, and we pretty much just passed out. Getting to Africa is not a short journey by any means!

Monday was a whirlwind tour of the city. We started by walking down to the main road and soliciting a 'matatu,' which is basically a minivan which functions as a public bus. There are hundreds of matatus buzzing around the city constantly but each one will try to charge you a different amount. Haggling for prices seems to be part of life here, as I soon found as we entered the main market of the town. Fruits, vegetables, spices, lentils, animals, all squeezed closely together with almost no room to walk, and people everywhere made this market hard to navigate but exciting to explore.

The city is overwhelming, especially for foreigners. The city is dense with people, and the streets are filled with cars, vans, motorcycles and bikes moving in a sort of organized chaos. It is a surprise to me that more people aren't hurt in the traffic, but I think that being able to navigate the roads as a pedestrian or hail down a matatu is definitely a rite of passage here.

Later that day, we met with a couple medical students from Makerere University, which is one of the largest and most prestigious universities on the continent. The students here have formed a group called Students for Equity in Healthcare (SEHC) (PDF), which is similar to PHR in the US. We got a tour of Mulago Hospital where they do their rotations, as well as their medical school. It was simply amazing to see so many highly motivated medical students who are doing such positive things in their country.

The medical school itself is quite large, but is also very old and not up to standards that we hold as the norm back at home. Can you imagine preparing your own microbiology slides and studying Biochemistry from donated books published in the 1950s? Would you be able to survive in medical school without a laptop or easy access to the internet? Many of us might have shied away had we been required to study in an environment such as this; I know I certainly would have thought twice. But that is where the difference is; I didn't realize how privileged I am until I came here and saw how hard these students work.

Worse still, graduating students here are not guaranteed good jobs or decent pay. It is not uncommon to find trained health professionals selling vanilla beans in the market because they can make more money that way. Even though I don't know the SEHC students very well yet, I already have an immense amount of respect for them. They chose this profession out of such genuine commitment to health as a human right and out of desire to protect that right no matter how difficult it might be.

The rest of our week promises to be quite eventful. On Tuesday we are going out to the rural Lyantonde district to visit a healthcare facility that uses a community-based approach. On Wednesday we will meet with officials from the Ministry of Health as well as some NGOs that are working on health equity and justice in Uganda. Thursday through Saturday will be the conference, which is what I am most excited for!

Darfuri women in a refugee camp in Chad. (Photo by Michael Wadleigh, gritty.org for Physicians for Human Rights)

People are worried about Sudan. Following the International Criminal Court's arrest warrant for President Omar Al-Bashir, nearly all humanitarian organizations were expelled from the country. Overcrowded refugee camps in Sudan and neighboring Chad offer little hope for the 1.1 million people now left without essential food, water and medical aid. The entire world is wondering, "What do we do now?"

This is the question that will be addressed at a breakfast panel discussion on Tuesday, April 14, 8:30am (EST) at the National Press Club in Washington, DC. The panel includes PHR's own Karen Hirschfeld, Darfur Survival Campaign Director.

Karen will discuss new data on sexual violence in Darfuri refugee camps. Myriad factors contribute to the rampant sexual violence documented by PHR at these camps; an influx of more refugees will only exacerbate these conditions. The event will be hosted by Jody Williams, who shared the 1997 Nobel Peace Prize with PHR, for their work on the International Campaign to Ban Landmines.

This week's Senate confirmation hearing for President Obama's nominee for Secretary of Health and Human Services (HHS) offers a key opportunity to press the Administration on its plans to end the US ban on the entry of people living with HIV/AIDS.

With last summer's passage of PEPFAR, Congress removed the statutory requirement to deny people living with HIV entry into the U.S as visitors and immigrants. However, HIV remains on the HHS list of "communicable diseases of public health significance," preventing the entry of people living with HIV into the US, despite the lack of scientific evidence supporting the ban as an effective strategy for preventing HIV infections or reducing public healthcare costs. The current law also violates the human rights to privacy, freedom of movement and freedom from discrimination.

Pat Daoust, MSN, RN, the Director of the Physicians for Human Rights Health Action AIDS campaign, said today:

It is far past time for the US to join the community of nations whose HIV entry policies are rooted in sound public health practices, rather than discrimination and ignorance.

What You Can Do

Senators can use the confirmation hearings for President Obama's Secretary of HHS to urge the nominee, Kansas Governor Kathleen Sebelius, to lift the ban swiftly once in office.

Contact Senate committee members Mikulski and Sanders and urge them to press Secretary-designate Sebelius on the Obama administration's plans for repealing the highly discriminatory ban.

You may reach Senator Barbara Mikulski's office at (202) 224-4654.

You may reach Senator Bernie Sanders' office at (202) 224-5141.

Suggested script for your call:

• Hello, I am a member of Physicians for Human Rights calling regarding the confirmation hearing of HHS Secretary-designate Kathleen Sebelius.
• I would like the Senator to ask a question regarding her plans to remove HIV from the list of communicable diseases that prevent entry to the US.

Travel restrictions violate the human rights of people living with HIV and place the US among 14 countries that either refuse entry of people living with HIV or require disclosure of HIV infection even for short-term stays. With your help, we can ensure that reducing HIV discrimination and defending human rights is a priority for Secretary Sebelius on day one.

A woman with her daughter visiting a Marie Stopes Kenya outreach site, where she can receive family planning and VCT services. (Amanda Cary/PHR)

For the past month, we've been posting stories and lessons learned from Kenya regarding the integration of family planning and HIV/AIDS services as a critical strategy to halt the feminization of AIDS. This weekly blog series—kicked off in honor of International Women's Day on March 8—draws from a December 2008 Physicians for Human Rights trip to Kenya, where I joined Lisena DeSantis, Health Action AIDS Kenya Program Associate, to learn about integrated services directly from the providers, clients, local NGO staff and government officials with firsthand knowledge.

Throughout our many conversations, we heard the message loud and clear: integration of family planning and HIV/AIDS services provides critical linkages to HIV/AIDS prevention, care and treatment (PDF) and in this way serves as a vital intervention in stopping the feminization of the AIDS epidemic.

Furthermore integrating these services is a powerful strategy to decrease physical and social barriers to the health system and provide more services in more places for more people. In other words, it is a strategy that actualizes a right to health framework by promoting the availability, accessibility, acceptability and quality of health services.

It is obvious. Mothers who come to the health facility for family planning want to take advantage of the [voluntary counseling and testing for HIV] because they overcame barriers to get here. If I come here, I get family planning and voluntary counseling and testing. That is a package. That is access. (Dr. Muguche, Manager of Outreach for Marie Stopes Kenya)

Indeed, it is obvious. We, as advocates for the right to health, must reinvigorate strategies and policies for implementing integrated family planning and HIV/AIDS services on a global scale. While advocacy around PEPFAR reauthorization had many successes last year, the reauthorized bill still does not give the necessary attention to family planning services in the fight against AIDS.

One of our challenges now is to ensure that the PEPFAR 2 implementation strategy makes the integration of HIV and family planning services standard practice in PEPFAR-supported HIV service delivery. In the coming year, PHR will be meeting with policymakers and PEPFAR officials to demonstrate the importance of creating one stop shops to fight the AIDS epidemic and promote the right to health.

As our work continues, I will remember Emma, the nurse and fellow health professional advocate who offers a one stop shop with family planning and HIV/AIDS voluntary testing and counseling (VCT) services for her clients in Kenya. Emma began providing her one stop shop after witnessing the struggle her clients faced to access health services and recognizing the right of each of her clients to be cared for holistically within the health system. Emma shows us that providing comprehensive services for women is by no means impossible. Yes, there are major gaps and major needs; but health workers, such as Emma, are changing the paradigm and demanding more from the system they work in, looking for the simplest, most cost-effective way to provide the needed services. Indeed, they are blazing a trail for the rest of us to follow.

Additional Resources

• Halting the Feminization of AIDS: Lessons from Kenya (slideshow)

Peter Mugyenyi (center), MD, with White House staffers Gayle Smith (left), senior global health advisor to President Obama at the National Security Council, and Jeff Crowley (right), director of the Office of National AIDS Policy.

Wrapping up a week of Congressional meetings and public engagements, Dr. Peter Mugyenyi and PHR staff met with Gayle Smith, senior global health advisor to President Obama at the National Security Council, and Jeff Crowley, director of the Office of National AIDS Policy. Dr Mugyenyi laid out PEPFAR's tremendous contributions in sub-Saharan Africa and the need for increased resources on the ground. We also discussed future directions in global health and the roles of PHR and health professionals in those efforts.

Earlier in the week, Dr. Mugyenyi had dinner with Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, and some of his colleagues where they reflected on PEPFAR's creation and successes to date, while discussing innovative interventions for a future free of AIDS.

Dr. Mugyenyi was in Washington from March 16-20 as a special guest of Physicians for Human Rights (PHR). During the week he met with more than 15 members of Congress, spoke at a Congressional briefing on health workforce shortages, and gave speeches at the Center for Strategic and International Studies and Georgetown University. See audio and video links below.Dr. Mugyenyi said:

We made it abundantly clear that the AIDS situation is still escalating in Africa and that we are only reaching a tiny minority of those who need treatment, while a high number of people are still getting infected. We all appreciate the great difference PEPFAR has made in a horrible situation in sub-Saharan Africa. All of PEPFAR's good work would be undone if funding levels are not increased at this time.

Global health advocates are urging a total US commitment in 2010 of $9 billion for bilateral HIV/AIDS programs and $2.7 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria.

In the current economic climate, the road ahead for sustaining US commitment in global health will be rough—but the week in Washington proved once again that health professionals can keep up the momentum and gains of the last years. Please stay in touch with us and contact Jirair if you want to be more involved in our work: jratevosian [at] phrusa [d0t] org.

Audio and Video from Peter Mugyenyi, MD, in Washington, DC

• Remarks at CSIS
• Remarks at Georgetown University, also featuring Amb. Mark Dybul, former US Global AIDS Coordinator
• Interview on Voice of America's Nightline Africa

Next week, members of Physicians for Human Rights from all across the country will be meeting with their Member of Congress district offices and asking them to stop AIDS now! We have scheduled meetings in 25 states with 63 Members of Congress from Boston, MA to Honolulu, HI.

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Peter Mugyenyi, MD, showed us last week that scaling back US commitments to fight AIDS is a "Recipe of Chaos." Millions of people depend on US funding for HIV/AIDS treatment, prevention and care. Health professionals and students we can help ensure they get the care they need.

After Dr. Ahmed visited us at PHR on Monday, he was interviewed by Boston Globe reporter James F. Smith, who blogged the Dr. Ahmed's comments yesterday and adapted the piece for a newspaper feature today.

[Dr. Ahmed] said that after visiting with decision-makers in Washington, he is worried that the Obama Administration still lacks a clear strategy for the Darfur crisis.

“There is no clear plan yet to deal with Sudan in this country,” he said in an interview. “We are urging this country, which gives more than 70 percent of the aid to Darfur, that it is time to stand up and say the right thing…. Americans should be sure that this money and aid goes to the the targeted groups.

“We need a very transparent mechanism. And we need more pressure,” he said, adding that “US officials are sympathizing very much, but they still don’t have clear policies.”

Ahmed said the stress on internal refugees because of the food and water crisis may drive thousands more to make the dangerous trek from Darfur to camps in neighboring Chad. He said residents of some camps in Darfur are refusing to work with Sudanese government officials who are trying to take over the food distribution duties of the expelled groups….

The reduction of food rations for residents of the camps has left the elderly and children more vulnerable this time, he said, and there are also reports of increased tuberculosis and diarrheal diseases.

All of that raises the risk of more Darfurians trying to flee to Chad, he said.

Smith also spoke with Karen Hirschfeld, Director of PHR's Darfur Survival Campaign, who visited the camps in Chad in November, while studying women's rights violations.

“There is clearly not the capacity in the camps to deal with thousands of additional refugees," she said. "If 100,000 refugees come across border, the camps cannot cope. The security situation is precarious. Aid agencies are delivering just basic services. The infrastructure has been degreaded by already dealing with 250,000 refugees; they are not in a position to deal with tens of thousands more.”

Excerpts from first hand accounts of Darfuri women who will be featured in Karen's forthcoming report are available on DarfuriWomen.org.

So the good news is that the cholera epidemic in Zimbabwe is finally getting under control. Weekly case fatality rates have dropped from over 5% to now about 1%. The bad news is that tuberculosis may soon take its place as a leading cause of death in Zimbabwe. According to the WHO, Zimbabwe has the the fourth highest incidence of TB in the world.

When the government finally admitted four months following the cholera outbreak last year that it did indeed face a spiraling epidemic, the ZANU-PF regime funneled the meager resources it did have toward combating the disease. One of the problems with this vertical health approach, however, is that it redirected resources away from other pressing health issues.

Enter tuberculosis.

When PHR investigators spoke with physicians at Beatrice Infectious Diseases Hospital in Harare, they reported to us that they could no longer treat their TB patients because government authorities mandated they only treat people infected with cholera.

The current health crisis in Zimbabwe poses other major problems including a dysfunctional national laboratory, a lack of diagnostic capacity and a severe shortage of first-, second- or third-line drugs to treat TB. Do you hear the din of alarm bells? They're sounding the spread of multiple-drug-resistant TB (MDR-TB) and the most severe form, extensively drug-resistant TB (XDR-TB). These highly lethal forms of TB develop and spread rapidly because treatment interruptions allow the bacillus to evolve and evade the antibiotics by various cellular mechanisms.

Drug-resistant variants of TB are arguably more of a threat to southern Africa than the spread of cholera, which is an acute illness that remains both treatable and curable with basic medical services. Drug-resistant TB will pervade in the regions for years and will greatly increase the cost and complexity of treatment and care.

>> Learn More: PHR’s Zimbabwe report, videos and advocacy opportunities

Mohammed Ahmed Abadallah, MD, from Darfur, speaks to PHR staff and guests. (Ben Greenberg/PHR)

In the face of a rapidly escalating humanitarian crisis in Darfur, PHR staff met yesterday with our friend and colleague Mohammed Ahmed Abdallah, MD, a physician and Professor of Medicine at el-Fasher University in Darfur, Sudan and a member of the Sudanese Center for Rights Promotion and Peace Building. Dr. Mohammed was formerly the medical treatment director at the Amel Center for the Treatment & Rehabilitation of Victims of Torture in Darfur, offering services and support to survivors of torture and sexual violence while documenting violence and human rights abuses. He is a highly respected community leader, peace negotiator and human rights advocate in Darfur and around the world.

Dr. Ahmed is in the US for several weeks meeting with policy makers and NGOs on the crisis in Darfur. He met with all PHR staff for an hour today to update us on the situation on the ground in Darfur. His reports from the field are devastating and make real the desperation of the Darfuri people. In the last 3 weeks, the Sudanese government has expelled 13 foreign humanitarian aid groups and 3 Sudanese groups from Darfur. Groups which have been the lifeline for Darfuris for years—including Oxfam, CARE, MSF Holland, Save the Children UK, IRC and Mercy Corps—have had their licenses revolved and have had to leave the country.

Nasser Weddady, Civil Rights Director of the American Islamic Congress (left), asks Mohammed Ahmed Abdallah, MD (right), a question about the situation in Darfur. (Ben Greenberg/PHR)

Doctors, nurses and other medical personnel have been forced to leave their patients behind. Dr. Ahmed reports that up to one million people have no access to water. People have no medical care. And there is very little food. Human rights groups have been closed and cannot provide support for victims.His urgent plea to the US and to the international community: Something must be done now to stop the suffering in Darfur.

PHR staff and guests listen to Mohammed Abdallah, MD (center). On the right, in the foreground is Darfur Survival Campaign Director, Karen Hirschfeld. Directly behind Dr. Mohammed, is Nasser Weddady, Civil Rights Director of the American Islamic Congress. On the far left: Dr. Nidal M. Sliman from the Robert F. Kennedy Memorial Center for Human Rights. (Ben Greenberg/PHR)

In the face of this devastation, take action today. Text Hillary Clinton at 90822 to tell her to make the humanitarian crisis in Darfur a top priority. Visit DarfuriWomen.org and read about a group of courageous women leaders in Darfur—and leave them a message of hope and solidarity. Follow updates here on the PHR blog. Make a donation to support PHR’s work to stop genocide and promote human rights. Dr. Ahmed will return to Sudan later this week; let’s help ensure the Darfur he returns to has food, water, health care and protection—fundamental human rights we must fight for.

Today, March 24, is World Tuberculosis Day. On World TB Day, we celebrate and commemorate the lives of those who have been affected by TB across the globe.

According to the World Health Organization, about 1/3 of the world population is infected by the TB bacillus. TB poses one of the greatest public health risks of our time. According to the Stop TB Partnership, four out of ten people who become ill with tuberculosis fail to get accurate diagnosis and effective treatment. As a result, drug resistant TB is on the rise in many countries and is not being addressed with sufficient speed or commitment.

Considering the incredible risk posed by drug-resistant TB, I am saddened and troubled by reports from our partner in Uganda, the Action Group for Health, Human Rights and HIV/AIDS (AGHA), about a TB drug stock-out in Mulago Hospital, Uganda’s National Referral Hospital based in Kampala.

The Stop Stock-Outs Coalition put out the following statement yesterday, regarding these disturbing trends:

For the last seven months, since October 2008, Mulago Hospital has been experiencing shortages of anti-TB drugs. These shortages have been affecting not only Mulago Hospital, but also the sub-district health centres. This is disastrous to Uganda’s efforts to prevent and eliminate TB cases in the country. According to the World Health Organization (WHO), Uganda ranks 15th in the world for TB burden. Mulago hospital receives about 25% of all the country’s TB cases, attending to 250 or more patients every month. Mulago is not the only public health facility affected; TB medication stock-outs are also being experienced at sub-district health centres across the country.

This ongoing situation is totally unacceptable. Children with TB have not been able to get TB treatment at Mulago Hospital because there have been no pediatric TB medicines at the hospital since December 2008. Even more alarming, are the reports that Mulago Hospital’s stocks of ethambutol/INH combination (a TB medicine used in the continuation phase of TB treatment) expired in January 2009 and some patients are currently receiving expired medication! Ironically, while the slogan for this year’s World TB day states “I am stopping TB”, the Ugandan Government, by allowing this situation to prevail, is doing the opposite, and instead is promoting the spread of the disease because:

1. Patients identified with TB have to delay starting treatment because of the stock-outs. This delay means that these TB patients can potentially infect more people. It is important for someone infected with TB to start medication as quickly possible, because the chance of infecting another person is drastically reduced after even one week of treatment.
2. The stock-outs mean that patients who are already on treatment will have to interrupt the course of treatment because the medicines they need are not in stock. Patients who interrupt their treatment are at increased risk of developing multi-drug resistance (MDR) TB. This exacerbates the crisis as MDR TB is more expensive and more difficult to treat.

Sandra Kiapi, Executive Director of AGHA and member of the Stop Stock-outs Ugandan campaign says:

This situation is totally unacceptable. The slogan for this year's World TB day is, 'I am stopping TB', but by allowing this situation to prevail, the Ugandan Government is doing the exact opposite.

The statement goes on to explain that TB medications are among the list of essential medicines that the Government is obliged to make available to Ugandans free of charge under the Uganda National Minimum Health Care Package. By neglecting to take action on these stock-outs, the government of Uganda is failing to meet its moral obligations to its people, as well as its human rights obligations under the International Covenant on Economic, Social and Cultural Rights (ICESCR).

The New Vision, one of Uganda’s daily newspapers, also published an article on the TB stock-outs, which quotes Justin List, a PHR student leader currently living in Uganda.

Stock outs of essential medicines have been an ongoing issue in Uganda. AGHA published research in 2007 on stock-outs of essential anti-malarial medicines which has raised awareness about how medicines stock-outs are effecting health facilities at the community level.

Ensuring continual access to TB medications is essential in order to control this vicious disease and stop the spread of drug-resistant TB. The Government of Uganda must immediately take action to make available quality TB medications at Mulago Hospital and all other public health facilities in the country where there are stock-outs and address the bottlenecks in medicines procurement, supply and distribution that contribute to the ongoing stock-outs.

On this World TB Day, we must hold all governments accountable to their commitments and obligations to addressing this global epidemic. Access to TB medications and proper care for those infected must be guaranteed if we are serious about stopping TB.