Can’t make it to the Wilson Center? Tune in to our podcast to hear expert speakers on the links between global environmental change, security, development, and health. Includes contributions from the Environmental Change and Security Program (ECSP) and Maternal Health Initiative (MHI).
ECSP and MHI are part of the Woodrow Wilson International Center for Scholars, the living, national memorial to President Wilson established by Congress in 1968 and headquartered in the District of Columbia. It is a nonpartisan institution, supported by public and private funds, engaged in the study of national and world affairs. The Center establishes and maintains a neutral forum for free, open, and informed dialogue. For more information, visit www.wilsoncenter.org/ecsp and www.newsecuritybeat.org/.
Lessons from Africa: Building Resilience through Community-Based Health Systems
If there’s anything about responding to an epidemic, it’s that speed matters, and so does investing in people closest to the problem, said Dr. Raj Panjabi, Assistant Professor of medicine at Harvard Medical School and CEO of Last Mile Health, in this week’s Friday Podcast. The latter, he said, is the root of resilience.
In addition to threatening immune systems, COVID-19 is a serious threat to the broader health system and to non-COVID-19 health care. Drawing on lessons from the Ebola outbreak, Panjabi said that the best system is an everyday system capable of surging in a crisis. Creating such a system would involve sufficiently funding community health workers before communities experience a state of emergency.
In the absence of existing and well-funded health systems, communities are left scrambling in a crisis and quality of care declines as a result. During the Ebola epidemic, the availability of skilled facility-based birth attendants across Liberia plummeted three-fold because health workers were becoming infected, Panjabi said. To complicate the issue further, health systems had poor infection control, and people were afraid to go to the hospital. Even in low-transmission areas, expectant mothers who believed they could get an infection from a health worker in a health center were about 50 percent less likely to go to the hospital for the birth, said Panjabi.
However, there were cases of strong community-based responses. South Africa, for instance, had about 27,000 HIV & TB community health workers who were retrained. They went on to screen more than 11 million people—about 20 percent of the population— and help detect COVID-19 at the community level in the first months of their pandemic, Panjabi said. South Africa managed to do this because it had been already investing in everyday health workers. And Liberia has improved its health systems since Ebola as well. One in two rural children with malaria are being tested and treated “by their neighbors, by community health workers,” said Panjabi.
These case studies illustrate why it is crucial that community health workers in Africa—most of whom are women from poor communities—should be viewed as invaluable employees rather than as informal volunteers. After all, investing in community health workers is not simply a health issue, said Panjabi. The COVID-19 pandemic has been a reminder that robust health systems can benefit both the economy and the security of nations, he said. Based on fiscal stimulus projections from the UN Economic Commission for Africa, Panjabi said that allocating just $2 to $4 billion of a $100 billion budget would help fund a potential pandemic health workforce that could not only help us deal with this current pandemic but help us become better prepared for the next one.
For every dollar invested in community health workers, there is ten dollars’ worth of economic return. That stimulus provides protection against the next outbreak and allows patients to lead longer, healthier, and more productive lives, said Panjabi. “But it’s also one of the fastest ways to create jobs for young people on the continent,” he said.
The Importance of Community Trust to Combat COVID-19 Vaccine Hesitancy
“Vaccine hesitancy is to be expected in a normal circumstance—it’s very different from being what we call ‘anti-vaccine,’” says Dr. Rahul Gupta, Senior Vice President and Chief Medical and Health Officer at March of Dimes, in this week’s Friday Podcast. He spoke at a recent Wilson Center event on ongoing efforts to develop and deliver a COVID-19 vaccine, co-sponsored by the University of Pittsburg, March of Dimes, and the Jonas Salk Legacy Foundation. "It is normal for average citizens and residents to be questioning the vaccine before they take it into their bodies. That's where the transparency of the manufacturing process, the regulatory process, and building trust in that system is so critical and important. It is not wrong, at all, to be hesitant. What is important is to demand that we have a safe and effective vaccine," said Gupta. “Leadership matters,” said Dr. Lisa Waddell, Chief Medical Officer of COVID-19 Emergency Response at the CDC Foundation. “If we have a consistency in messaging around the vaccine and everyone is actually sharing that message, then yes, it is going to build trust.” It is important to communicate early, often, and in different ways to ensure that people receive these messages, said Waddell. We also have to consider the role health inequities and racial injustices play toward vaccine hesitancy, particularly in African American and Latinx populations, and provide information on the COVID-19 vaccine and address concerns through trusted messengers, said Gupta. “It is good to ask questions and it is good and important to have trusted messengers in front of you who can answer the questions, who can relate, who can communicate,” said Dr. Paul Duprex, Director of the Center for Vaccine Research and Professor of Microbiology and Molecular Genetics at the University of Pittsburgh. “We have before us a national and a global teachable moment when it comes to vaccines,” said Dr. Ruth A. Karron, Director of the Center for Immunization Research and the Johns Hopkins Vaccine Initiative at the Johns Hopkins Bloomberg School of Public Health. While vaccines are regularly researched, developed, and deployed, the process is not often on center stage. This gives us an opportunity to really educate the public, said Karron. “And I think that if we do this right, we could not only increase confidence in COVID-19 vaccines, but increase confidence in all of the vaccines that we deploy.” “It's important to remember that we need to champion these products, we need to show what they have done in the past,” said Duprex. Polio, which ravaged the world’s youth for decades, has been “pushed to the edge of eradication by safe, efficacious vaccines,” he said. “I think we have to remember not to forget. Not to forget what these diseases did in the past and to actively collaborate, to work with each other, and to communicate well that vaccines work.”
The Resurgence of Indigenous Midwifery in Canada, New Zealand, and Mexico
Globally, Indigenous women experience worse maternal health outcomes than non-Indigenous women. In the United States, the risk of maternal death is twice as high for Native women than for white women, while in Australia the risk is four and a half times higher. This week’s edition of Friday Podcasts highlights remarks from a recent Wilson Center event with the United Nations Population Fund (UNFPA) and the International Confederation of Midwives about Indigenous midwifery.
“The decline of Indigenous midwifery really happened through the outlawing and the denigration of Indigenous midwifery, and was an attack on our Indigenous knowledge systems, our ways of being, our ceremonies and our practices,” said Claire Dion Fletcher, an Indigenous Potawatomi-Lenape Registered Midwife and co-chair of the National Aboriginal Council of Midwives. “The control of Indigenous women through the, at times, violent control of our reproduction was and continues to be a tool of colonization.”
“In the 19th century with the medicalization of birth, there was a decline of midwifery in Canada, almost to the point of non-existence,” said Fletcher. Yet Indigenous women still wanted to have traditional births according to their customs and knowledge. “The Inuit women in Nunavik wanted Inuit midwives,” she said. “They wanted to give birth in their communities with their families surrounded by their knowledge and their teachings.” To this day, the resulting community-driven Inuit midwifery program has some of the “best health outcomes in the world,” said Fletcher.
Similarly, colonization played a key role in the decline of Indigenous midwifery in New Zealand, said Nicole Pihema, Māori Registered Midwife and President of the New Zealand College of Midwives. In New Zealand in 1840, British colonizers and Māori leaders signed a document intended to ensure that the British would not interfere in Māori life, said Pihema. But instead, the colonial government continued to interfere in Māori life by passing harmful legislation including the Tohunga Suppression Act of 1907, which led to the desecration of Māori midwifery practices. However, there is a resurgence within Māori midwifery to try to rediscover traditional practices, said Pihema. This resurgence requires a commitment to normalizing inclusive language, “because you can teach cultural competency all you want, but you're never [going to] get it unless you know the language,” she said.
“In Mexico, midwifery has existed even before we were colonized by the Europeans,” said Ofelia Pérez Ruiz (through a translator), an Indigenous Registered Midwife and spokesperson for the Chiapas Nich Ixim Movement of Traditional Midwives. “And traditional midwifery in Mexico has been here despite criminalization and going through exclusion policies,” she said. In Mexico, Indigenous midwives are not included in conversations about maternal health. “They [doctors and health institutions] don't take us into account as part of the maternal and neonatal care,” said Pérez Ruiz. “We want to have a relationship with health institutions, but based on respect. We wanted to work along and hand in hand with the doctors using those skills and knowledge of all of us as a team … so that indigenous women will receive a timely care and respectful care during their pregnancy, birth, and after birth.”
The State of Sexual and Reproductive Health and Rights: A Conversation with Dr. Zara Ahmed
“Unintended pregnancy and abortion are reproductive health experiences shared by tens of millions of people around the world, irrespective of personal status or circumstance. What differs though are the obstacles,” said Dr. Zara Ahmed, Associate Director of Federal Issues at the Guttmacher Institute in this week’s Friday Podcast. Research from the Guttmacher Institute on sexual and reproductive health (SRH) found that in 2018, there were 121 million unintended pregnancies globally, and of those, 61 percent ended in abortion. About half of these abortions were in unsafe conditions and led to approximately 23,000 preventable pregnancy related deaths, said Ahmed.
“A major finding of our research is about the legal status of abortion,” said Ahmed. “This is important. Abortion rates are the same where abortion is broadly legal and where it's restricted - exactly the same.” Guttmacher research shows that in settings where abortion is restricted, the proportion of unintended pregnancies that end in abortion increased nearly 40 percent over the last 30 years.
“There are persistent inequities in meeting needs for contraceptive services,” said Ahmed. Today, 923 million women want to avoid a pregnancy and among these women, about one in four, or 218 million, have an unmet need for modern contraceptive methods. Unmet need for modern contraception is higher in low-income countries and for adolescents than it is in high- income countries and for older women. In order to meet this global need for family planning, the United States must restore funding for UNFPA and increase funding for global family planning and reproductive health programs, said Ahmed.
The COVID-19 pandemic has threatened access to SRH services worldwide. A decline of 10 percent in access to SRH services, said Ahmed, would lead to “an additional 49 million women with an unmet need for modern contraception, an additional 15 million unintended pregnancies, an additional 28,000 maternal deaths, an additional 168,000 newborn deaths, and an additional 3 million unsafe abortions, as well as an additional 1,000 maternal deaths due to unsafe abortion.”
“In the middle of a global pandemic, the Trump administration is trying to make it harder for people to get the [SRH] care they want and need. A few weeks ago, the administration announced that it's proposing to expand the dangerous and harmful Global Gag Rule even further than it already has,” said Ahmed. The Global Gag Rule (GGR) is a policy that “prevents foreign NGOs that receive U.S. funds through grants and cooperative agreements from using their own non-U.S. funding to provide abortion services, information, counseling, referrals, or advocacy,” she said. Guttmacher research in Uganda shows that the GGR led to a “reduction in the number of community health workers, engaged in family planning work.”
“People are complex and they live multifaceted lives with changing [SRH] needs,” said Ahmed. The global community must invest in the full range of SRH services to meet these needs. “Doing so is a smart investment, but it's also the right thing to do.”
A National Reckoning: Highlights From A Conversation with Congresswoman Alma Adams
“I believe that we're experiencing a national reckoning and in this unique moment, I definitely see an opportunity for Congress, but also for our local governments to enact policies that begin to address our country's greatest ills,” said Representative Alma Adams (D-NC-12) at a recent Wilson Center event on women, race, and COVID-19 in the United States. “COVID-19 has revealed what the Black community and communities of color have known for a long time—health outcomes are further compounded by systemic and structural racism. COVID-19 has exposed what women have known for a long time—gender inequality exists, it threatens economic empowerment, and it increases vulnerabilities.”
“The pandemic has shown us in the starkest terms how wide the gaps are in health outcomes between Black and White America and between men and women,” said Rep. Adams. Black women, regardless of their educational level or socioeconomic status, are nearly four times more likely to die from preventable pregnancy-related complications than women of other races. “The United States has the highest maternal mortality rate among affluent countries because of the disproportionate death rate of Black mothers,” she said. “Black maternal health in the coronavirus era is truly a crisis within a crisis.”
“The pandemic has completely wiped out the historic job gains women have made over the past decade,” said Rep. Adams. Before COVID-19, women made up the majority of the U.S. workforce. They are highly represented in the sectors most impacted by the pandemic. Women are the majority of essential workers, and non-white women are more likely to be doing essential jobs than anybody else, said Rep. Adams. “The work that they do has often been underpaid, undervalued, and an unseen labor force that keeps the country running.”
While there has been a positive reduction in women’s unemployment since the pandemic’s onset, most of those impacted are mothers. 41 percent of mothers, and close to 80 percent of Black mothers are the breadwinners for their families, yet continue to face wage inequality. “They're doing the providing, yet they're not getting the income,” she said. “We deserve equal pay for equal work. You know working hard is not enough if you don't make enough.”
“We are finding that from the offset of the COVID-19 pandemic there has been an increase in gender-based violence around the world. For every three months of lockdown, there will be an additional 15 million cases of gender-based violence,” said Sarah Barnes, Project Director of the Maternal Health Initiative and Women and Gender Advisor at the Wilson Center.
“As a survivor myself of domestic violence, I know firsthand how important it is that we keep working to pass and strengthen legislation to improve services for survivors like the Violence Against Women Act,” said Rep. Adams. “I see a tremendous opportunity for Congress and our society, as well, to pursue transformational structural change because the system isn't working for so many people, especially women and minorities, and it really is time to try to do something else.”
Non-Communicable Diseases and COVID-19: A Conversation With Dr. Belén Garijo and Dr. Felicia Knaul
“NCDs have raised the risk of and the severity of the COVID-19 infection,” says Dr. Belén Garijo, Executive Board Member and CEO of Healthcare at Merck KGaA Darmstadt, Germany, in this week’s Friday Podcast. Women living with NCDs like cardiovascular disease, hypertension, cancer, mental health disorders, multiple sclerosis, and diabetes, have an increased risk of severe complications and death from COVID-19. “When you take a look at the mortality rate for one million inhabitants, you see a lot of diversity, and what has been consistent amongst all the countries is the association between severity of the infection and underlying diseases,” says Garijo.
“We know that this pandemic is affecting women in a number of ways that are very harsh compared to men,” says Dr. Felicia Knaul, an international health economist and founder of Tómatelo a Pecho. Since the onset of the COVID-19 pandemic, women have experienced “more unemployment, more lack of access to jobs in all but the health sector, more issues of caregiving and less ability to earn income, more exposure to domestic violence.”
“In the U.S., women accounted for up to 55 percent of the 20.5 million jobs that have been lost in April. In February, the unemployment rate for adult women was 3.1 [percent], in April this has gone up to 15 percent. In the same period, the unemployment rate for adult men was of 3.6 percent. And in April, this rate, 13 percent,” says Garijo. “The risk that we're facing is that we will see the gains of decades—which were not enough, but were still gains—in gender equality being eroded if we're not careful,” says Knaul.
“This pandemic has really changed the way we are looking at our research focus,” says Garijo. “I can tell you that we have, right now, almost completely focused our efforts in finding solutions for pandemics. I am hoping that we will never forget this, and that our pandemic preparedness will stay strong for the future in any and every continent. As an industry, we can never do that alone. We need to collaborate with others. We need to collaborate with governments. We need to collaborate with academic institutions, with healthcare professionals, with patient associations.”
“You cannot have strong health systems if you don't include women, not least which, because they are the majority of providers today.” says Knaul. “We've been working on some ideas around how to strengthen health systems in the face of COVID-19 and the first and key lesson is that this cannot be done without a gender transformative response.” A gender transformative response requires the inclusion of all genders, “otherwise we would never be strong enough, not only to respond to the COVID-19 onslaught, but what we're talking about today, which is the incredible onslaught of NCDs that face low- and middle-income populations and countries, as well as, high-income countries.”
“I am absolutely sure that you are aware of the articles highlighting that countries that have performed better against COVID-19 are led by women. I have to say that I don't believe this is by chance,” says Garijo. “Female leaders promote the more inclusive leadership model and they are willing to listen. They are willing to listen to diverse opinions and voices. They don't believe they know it all.”
This podcast is part of the Maternal Health Initiative’s CODE BLUE series, developed in partnership with EMD Serono, a business of Merck KGaA, Darmstadt, Germany.