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Scalpel please, nurse… oh, wait!

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Surgeons stitch up a patient after an operation at Banadir hospital in Mogadishu, Somalia. by Tobin Jones

Rich countries need to use their medical resources to address the global lack of surgical equipment, argues Maziar M Nourian.

Imagine that during your travels you break your leg and are sent to the local hospital. There is a team of qualified clinicians and they recommend an operation – but are unable to operate because of a lack of equipment.

An unmet global need for surgical care has always existed, but only recently have we understood the severity of this problem. Diseases and injuries treatable by surgery are common worldwide, yet 30% of the world’s population receives only 3.5% of all surgical procedures. Proper equipment is just as vital to surgery as a trained surgeon, but the majority of surgical equipment used in the Majority World is old, donated and, within 6 months of being donated, no longer functional.

In the United States, it takes roughly 3 to 7 years for a new medical device to go from the bench to the bedside or, in this case, the operating room. Most of these new innovations have to go through a stringent Premarket Approval (PMA) process to determine efficacy and safety. There are ways to ‘fast track’ the PMA. If a medical device contains only minor differences from a previously approved product, the device can downgrade into a class with a less-stringent approval process. This means less time and money are spent proving safety and efficacy and there is more time for the manufacturer to make money. Interestingly, devices in Europe need to be CE (European Conformity) approved but, fortunately, can go through this approval process 2 to 3 years faster than the US approval process. How does this relate to global health and surgery?

It is estimated that the global market for surgical equipment will grow from $8.43 billion (2012) to more than $11.28 billion (2019) with a compounded annual growth rate (CAGR) of 4.2%, with the fastest growth in Asia and the Pacific, at a CAGR of 16.1%. Surgeons and anaesthetists around the world need instruments to care for their patients. This is especially true in low- to middle-income countries, due to the volume and type of cases. There have been some innovative products from the high-resource world, such as Lifebox and One Breath. Other innovations originate in low-resource environments, for example the Jaipur foot, a significantly cheaper version of a prosthetic limb.

Pioneers in surgery, such as Dr TE Udwadia in India, have even invented (or re-engineered) laparoscopic surgical techniques because of the lack of adequate equipment. Just as impressive is the work done by Dr Benjamin Warf, who started CURE Uganda, a global leader in minimally invasive neurosurgery. Currently, multiple neurosurgeons around the world are training at CURE Uganda and the research has changed the way neurosurgery is practised in the developing world.

It is time for major manufacturers of medical devices in rich countries to use their power of innovation to address the needs of patients globally. Manufacturers should realize the potential market for their tools and make efforts to redesign existing technology to bring down the costs for those with little money. A barrier to this is Food and Drug Administration (FDA) and CE approval, but this can be mitigated by fast tracking an existing technology to adapt it for use in poorer countries with fewer resources. I believe everyone deserves access to surgical care. More importantly, everyone deserves to benefit from the ingenuity of the manufacturers of surgical equipment, and from the strict standards of FDA- and CE-approved devices.

As in Dr Udwadia’s case, desperation breeds ingenuity. If we can entice rich manufacturers to build appropriate technology, our colleagues in the under-resourced regions of the world will have powerful allies in the struggle to provide safe surgical care for their patients.

Maziar M Nourian is a 1st-year medical student at the University of Utah School of Medicine and he is interested in advancing global surgery and anaesthesia efforts.

Does anyone give a s**t?

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Cleaning toilets is a caste-based job in India Ignas Kukenys under a Creative Commons Licence

Growing up in Kolkata brought me face to face with homeless, poverty stricken people from an early age. Kolkata’s streets make it impossible to be shielded from poverty unlike some major Indian cities. As part of a student movement I worked in slum and village projects. Still, nothing, not even the worst Kolkata slum or 15 years immersed in adivasi (indigenous) villages, had prepared me for the face-to-face meeting with the filthy, inhuman reality of manual scavenging.

I have often written about scavenging in blogs for the New Internationalist and last year I described its practice and the recent struggle of the cleaners to throw down their brooms and ‘reclaim their pride’. Despite bills and acts being passed, real change is needed.

The first time I came across manual scavenging was in the state of Gujarat. I followed Leelaben, a sanitation worker, on her 6am trek to the huge, dry latrine which was her workplace. It took all my self control not to vomit violently. As I watched her sweep liquid shit into a basket with her bare hands and a broom, my stomach convulsed. That was January 1997. My journey into the world of manual scavenging and dalit* issues began through dalit leader Martin Macwan with the Navsarjan Trust in Ahmedabad, the former capital of wealthy Gujarat.  

In 1993, India passed the Abolition of Manual Scavenging Act. Gandhi began the debate in 1901 when he talked about the shame of manual scavenging and untouchability at a national political meeting. The issue was raised by other politicians with monotonous regularity. Monotonous because nothing changed for the oppressed community, the debates remained mere rhetoric and hot air. The passing of the 1993 Act armed activists and human rights lawyers with a weapon to fight for the rights of the people, mostly women, who still carried shit on their heads. I wrote an article in Frontline magazine in 1997 as India celebrated 50 years of independence. And then I wrote a book, Endless Filth, in 1999. I covered most states of India and I was happy to see change being brought about by Action Aid, shortly followed by Christian Aid that sponsored work to stop the scourge.

The Safai Karmachari Andolan (SKA) (Sanitation Workers’ Movement) led by Bejawada Wilson did a tremendous job. The entire team were from the community of balmikis, caste-based cleaners; the only people in India who were destined (condemned more like) for centuries to clean human and animal excreta. The SKA team were committed and passionate, it was their personal war for themselves and for future generations of their own people. The SKA led a nationwide movement and took the issue to the Supreme Court, backed by a team of dedicated lawyers and activists. There was a nationwide movement of protest and awareness raising which went from the northernmost Kashmir to the southernmost tip of Kanyakumari and there was a famous declaration of the end of manual scavenging. But today, hundreds of thousands of women continue to manually clean excrement in private and public toilets all over India.

About ten years ago, I interviewed Ashif and LaliBai, founders of the Rashtriya Garima Abhiyan (National Campaign for Dignity and Elimination of Manual Scavenging), who recently led balmiki women on a national journey or yatra to abolish manual scavenging. The Maila Mukti Yatra or the ‘Freedom From Shit journey’ covered more than 10,000 kilometres, 200 districts and 18 states in 65 days. They knocked at the doors of more than 200 parliamentarians, organized various events and protests and held hundreds of meetings with the different ministries, state governments, the National Advisory Council, Planning Commission and various political leaders.

Meanwhile, other groups and individuals have worked quietly and diligently all over India to educate balmikis and move them out of the dehumanizing occupation. A new Bill has been passed 20 years after the 1993 Act. Yet this hasn’t excited me. Having watched and documented the struggles of this community since 1997, I’m cynical.

Highlighted repeatedly by the human rights activist A Narayanan and G Israel, a social worker, both from Chennai, are the sickening deaths of sanitation workers all over India everyday. These men die by asphyxiation. They are hit by toxic gas as they open manhole covers and fall in, unconscious. They literally drown in liquid shit. Yet no one gives a damn.

The Hindu newspaper’s editorial sums it up aptly. ‘Get serious’ it advised the government. The only new and encouraging feature of this recent bill is that it focuses on pinning responsibility on officials whose duty it is to ensure that these horrendous dry latrines are removed from every corner of their districts.

There is a crying need for better technology with regard to hygiene, and there must be rehabilitation opportunities for manual scavengers. But more importantly there needs to be the political will to eradicate a filthy aspect of India and liberate the balmiki community from this national shame.

* Dalits = members of the most discriminated against castes in India, historically regarded as ‘untouchables.’

Nigeria's ‘anti-gay bill’ is another backward step

On hearing the news of the passing of the Nigerian Same Sex Marriage Bill, 2011 (the SSM Bill)–  which seeks to criminalize anyone who either enters into a same sex marriage or witnesses, supports or aids such a marriage– my reaction was…well, I was too numb to immediately react. I could only think about the miserable state my country is in. But did I really expect anything different?

In an article for CNN, Chude Jideonwo points to the real purpose of the Bill which is to expand the existing legislation on homosexuality to include organizations and individuals who ‘register, operate or participate in gay…organizations.’ As he points out, this could well include criticisms of the Bill such as his article and this blog post.

I would like to draw attention to the parallels between: (1) ‘The Story of Thomas,’ tweeted by @rmajayi, about a young man abandoned on the roadside and left for dead in Ado Ekiti in southwest Nigeria; (2) the non-investigation of a gang rape of a young woman on the premises of the Abia State University– neither by the Abia State government nor the police; and (3) this week’s passing by the Nigerian Senate of the SSM Bill.

What each of these cases explicitly implies is that citizenship is not open to everyone. The state and its institutions of power, both secular and religious, determine who is and what crimes are to be granted recognition, who is worthy of saving, who is considered a loyal citizen and who can therefore expect justice.

Those who criticize the SSM Bill on the basis that Nigeria has more pressing legislative issues to deal with such as endemic corruption (an age-old obsession that everyone complains about but one in which everyone partakes with no-one seeing themselves as part of the problem) fail to make the connections between homophobia and sexual violence or a violence which allows a man to be abandoned next to a gutter in front of hundreds of shoppers and passers-by and to die through lack of attention and care. Even when a ‘good Samaritan’ did attempt to do something she was disparaged and accused of only wanting publicity for her acts!

The sexual harassment of women, or being silent in its presence, has become so normalized within Nigerian society it has gotten to the point where it is happening on a day-to-day basis, publicly and privately, online and offline, in actions and words and body language. Women are constantly being degraded and verbally abused or demeaned on social media sites. Homophobia is horrifically expressed and applauded. These are all continuums of sexual abuse which takes place without question.

It is this normalization of sexual abuse and institutionalized misogyny that allows the police and others in authority to feel comfortable in making statements such as ‘she wanted to be raped’ and to be wholly negligent in their investigations. It is what allows the government of Abia State and the university to sit quietly on the sidelines and do nothing.

With respect to these now normalized and legalized acts of violence, what happens when a woman or man is raped, beaten or murdered because they were perceived to be LGBTI (lesbian, gay, bisexual, transgenger and intersex)? Will the fact the victims are LGBTI be used by the attackers as a defense? What if the Abia rapists claim they gang-raped the victim because they suspected she was a lesbian? What if the abandonment of Thomas and others like him is justified on the basis of their sexual orientation? Although these are individualized acts of violence they are representative of a pervasive violence or threat of violence against queer people, women, children, the poor and the vulnerable.

The rationale behind the SSM Bill and its proposed counterpart in Uganda, is a huge deceit being spread by secular and religious leaders that decriminalizing LGBTI persons would be pandering to Western imperialists’ moral decadence. On the contrary these legislations are part of a continuity of Western imperialism and ‘European heterosexual inheritance’* which were forced on colonial subjects and are a mark of our continued colonial dependency.

*see: M. Jacqui Alexander, ‘Erotic Autonomy as a Politics of Decolonization: An Anatomy of Feminist and State Practice in the Bahamas Tourist Industry.’ In: Feminist Genealogies, Colonial Legacies, Democratic Futures. Routledge: New York, 1997.


Supermarkets battle for India's soul


Remember the time before supermarkets? Not likely, unless you’re pretty ancient. Western countries were taken over long ago. And it’s happening now in India in larger cities. The big news here is that the government is allowing foreign direct investment to enter India. Which means Wal-Mart and Tescos will be all over Mumbai, Bangalore, Chennai and Kolkata like a rash. Supermarkets began hitting India roughly ten years ago. But they are still inefficient, unfriendly and not hugely popular.

However, just like the average Brit, the average Indian can’t resist a bargain. And the supermarkets offer these on a regular basis. So families will go to the supermarket only to buy 20 kilos of rice if it’s a huge saving. But in a city like Bangalore, for example, except for the fairly wealthy, people prefer their friendly corner shops. Supermarkets will find it hard to compete with the personalised service our small grocers offer.

In Gudalur, the small town we’ve lived in for more than twenty five years now, I can phone the shop and read out my list of groceries, pick it up all packed and ready and pay at the end of the month if I'm broke! It keeps my monthly food bills really low as I tend to buy only essentials for an average Indian kitchen – rice, whole wheat flour, sugar, lentils, oil, spices.

The minute I enter a Bangalore supermarket, I end up spending about five times my normal budget – I pick up bargains: new, exciting-looking, non-essential stuff. I walk out, knowing I've been really silly. The average Indian does not like to waste money, except for the new younger generation, the IT, corporate world executives who earn so much, a few hundred saved on groceries is less important than their time.

India's poor survive because they are enterprising and use their ingenuity to reinvent themselves to survive. They don’t have a choice. If you don’t work and go that extra mile in the city, you would die of starvation. There's no safety net. No unemployment cheque on a Wednesday to keep your head above water. So when washing machines arrived for the middle classes, dhobis, India's intrepid army of washerfolk, moved into a new occupation. They set up small mobile ironing carts. You see them at every street corner in our metros, ironing huge piles of clothes with heavy duty, coal irons.

In Bangalore, I am charmed by the village atmosphere of the residential areas. I hear vendors announcing their wares in a sing song, a distinctive cry which reminds me of my childhood in Kolkata. Freshly baked bread was delivered to every doorstep by the bread man with a lightweight circular cane pannier on his head. Vegetable vendors arrive to haggle amiably with their regulars – there are varieties of greens, okra, tomatoes, gourds of all kinds – all offering fresher produce than the supermarket. Fruits follow and a plethora of other intriguing kinds of goodies.

This is life in middle class areas, not in the gated communities, the skyscrapers where the super rich live. It’s a nicer, more human sort of existence when you can chat with the vegetable vendor, when the ironing woman tells you her woes, when you can complain sociably about the rain or the scorching summer temperature.

I think, the average, urban Indian still prefers this kind of existence to the lure of impersonal megastores which, for most, allow only window shopping. The business page today announced that small shops are forming co-ops to fight the huge retail giants like Wal-Mart and Carrefour.

The David vs Goliath battle is likely to be televised. I think most people will wish them luck. Parliament is furiously debating foreign direct investment with the entire country watching. I certainly hope Real India manages to survive.

Who profits from the 7 billion population frenzy?


So, now we are 7 billion. Or maybe not.

Maybe we will be 7 billion next March – or maybe we already were last July.

Because if you read the small print from the United Nations, the week’s landmark date – October 31 – is ‘symbolic’.

But the frenzy in the build-up to the big day has had effects that should alarm anyone concerned with equality, human rights and the real causes of climate change. Even serious media outlets resorted to the 1960s language of ‘overpopulation,’  ‘explosion,’ ‘overcrowding’. Spectres of hunger, poverty and global turmoil were paraded as the products of population growth.

The underlying issues of inequality or fossil fuel use or financial speculation, fell by the wayside. The most dramatic projections of future world population (10 billion, or even 16 billion by 2100), were routinely chosen over the lower ones – such as the paltry 6 billion by the end of the century.

Now this is partly due to journalists needing to draw a simple, dramatic story out of the complex issue that is full of uncertainties, caveats, and conditional tenses. Not to mention the added complication of fertility rates declining across the world. But there is more to it than that.

In recent years the ‘overpopulation’ narrative has been increasingly and skilfully promoted by those whose interests it serves. This week has shown the extent to which their PR efforts have borne fruit, helping to pave the way for quick fixes and magic bullets that promise big bucks for some.

Here’s a short list of some of the beneficiaries of population hysteria:

Biotech industry: bouncing back from popular rejection with the claim that the only way to feed the projected nine billion by 2050 is with genetically modified food.

Fossil fuel sector: citing population growth to justify exploitation of new, even more environmentally damaging fossil fuels such as shale gas (they don’t like to refer to it as ‘fracking’ anymore for some reason) and oil from tar-sands.

Nuclear industry: positioning itself as the only one with the capacity to provide energy on the scale needed to meet the needs of the world’s future generations.

Financial services: cites ‘population pressure’ as proof of the value of investing in the food and farmland futures – a new hot asset for speculators.

Agribusiness: elbowing out organics and other sustainable methods to reassert itself, and its fertilizers and pesticides, to create yields fit for hungry billions.

Family planning industry: boosting its capacity to raise funds for family planning programs in countries with high fertility rates, such as those in sub-Saharan Africa. Coming to the rescue, agencies can put behind them their failures to respond to massive human rights abuses that resulted from coercive, target-driven and population control policies in China, India and, during the 1990s, in Peru.

There are other, more overtly, political beneficiaries of population panic. The anti-immigration lobby, for example, can point to the parts of the world where population growth is fastest, sub-Saharan Africa and the Indian subcontinent. Where will all those people go? Certain sectors of the environmental lobby, especially the somewhat misanthropic tendency that resents the presence of people (apart from themselves) in areas of natural beauty, have become their unlikely bedfellows. And there’s a new brand of sexism emerging against women and their wombs (‘the cause of overpopulation’) as exemplified in the sketches of US comic Doug Stanhope. (I write about all this and more in the recently published No-Nonsense Guide to World Population.)

For the record, I have nothing against family planning. I’m all for women everywhere having control over their own fertility and the empowerment that enables them to do so. I have no hidden agenda. A couple of responses to a recent blog I wrote for the Guardian newspaper wondered if I had a religious perspective and how many children I had. The answer to both questions is ‘none’.

But I wish we could focus on the issues that really matter: the inequality that creates poverty and hunger, the poverty and disempowerment of women that leads them to unwanted pregnancies, the need for serious energy conservation and investment in renewables to tackle global warming; and the criminally stupid wastage of food and natural resources.

In talking about population we cannot ignore the numbers. But we need to see them for what they are they are – estimates and projections of what may or may not happen in the future. The problems that face us today are the same, regardless of how many there are of us.

But by allowing ourselves to be manipulated by the population panic agenda and the simplistic use of scary numbers we are allowing ourselves to be controlled by some of those vested interests implicated in the world’s most profound problems and that stand to profit from exacerbating them.

It’s a bit like an abusive relationship – with the fossil fuel and finance industries, for example, presenting themselves as the saviours, the solution, the antidote, to our collective pain. Only they can make us feel better.

We don’t have to believe them, though.

Vanessa Baird is the author of The No-Nonsense Guide to World Population published by New Internationalist.

Let's make the economy work for the people

I'm quite chuffed because my last blog on Occupy Wall Street (‘Can America’s Spring change the world?’) now seems almost prophetic. An English friend said ‘we should be doing something similar here in Britain’ and a week later, I'm reading about tents pitched in the City of London, exhorting all to Occupy the London Stock Exchange on 15 October.

Back here in Gudalur, India, we've been thinking about how to bring justice into the economy for more than a decade now. From 1986, we, ACCORD, an NGO working with adivasis (indigenous people), began reclaiming ancestral land. To secure these rights, we implemented a livelihood strategy, planting tea to ensure land possession and an income for these people. But just when we felt things were going well, people had food for their families and malnutrition graphs were improving, the bottom fell out of our world. Tea prices crashed to rock bottom and our secure livelihood option disappeared.

Yet consumers in Bangalore, Bangkok and London never pay less even when the prices crash. Where does the extra profit go? The farmer is cheated, but so is the consumer, you, the person who buys food for your family. So why not unite poor producers with poor consumers, we wondered. Thus Just Change was born which did just that, allowing them to work together in mutually beneficial ways. Clean business is possible, we discovered.

Wall Street epitomizes all that’s wrong with the economy and we are delighted that our firm conviction, the idea that the economy should exist for people, appears to be echoed by protesters across the globe. Just Change is taking its next big step soon, hoping to rope more investors into the family. In collaboration with The Global Institute For Tomorrow, a Hong Kong-based think tank, Just Change will unveil a pioneering new concept called ’participative capital’, which allows ethical investors to link with producers and consumers across the world in ways that ensure a more just, equitable and sustainable economy.

We must throw out the clichés of both communism and capitalism. No more jargon. Our participatory model allows for investments to be made in a manner where ownership, benefit and risk are shared by all. This is possible only if we radically redefine the role of capital, otherwise the divide between those who have the money to invest and those who do not will only increase. This alarmingly widening gap is at the heart of social unrest across the globe and is a recipe for disaster.

The meeting to talk about participative capital and ethical investing will be held in Bangalore on 11 November, 2011. We would love people from across the globe to join us as investors. We don't merely want money. We want people who are excited by the concept, who believe that equity and justice should be the cornerstone of all business, which includes paying farmers and producers a decent price, not merely out of a sense of fairness. It’s about going a step further by making them equal partners in the food supply chain.

We hope to create a webinar to enable people to join us in Bangalore. If you wish to be a part of the global Just Change family, do send us sound bites, tiny video clips and your pledge as an investor. It's really exciting, we have people who want to Just Change the world from the US, Canada, UK, Germany, India, and even Africa.

The internet is a key player in every new revolution! If you'd like to be a part of it, please write to us. We will send more details to those who express interest. Do come on board.