NEWSBYVICTOR ROY

When we think of cancer, the image is often of patients in the industrialized world, fighting courageously with the support of world-class physicians and the latest innovations in treatment. Almost everyone knows of someone who has faced this scourge. My maternal grandmother, Fullara, was one such person. But her story expands and transforms this classic image of cancer.

Dida, as I called her affectionately in my native Bengali tongue, succumbed to ovarian cancer five years ago this month, enduring an illness which mapped across geographical borders and socioeconomic gradients. At the time in her late 50s, my grandmother learned about her initial cancer diagnosis while on an extended visit in the U.S. to spend time with her grandchildren. Our summer turned to her health, as we stood alongside her and shared frequent updates with our anxious extended family half a world away in India. Eventually, with the help of a terrific medical team and the support of charitable care offered in New Jersey, she healed after a major surgery and several rounds of chemotherapy. Healthy and filled with strength, she returned to her home in a rural village near Kolkata, India.

But within two years, pain returned. This time, a return to the U.S. was without question — no insurance would cover a patient with her prior history, and the out-of-pocket costs would be too exorbitant for our family. Instead, our family did our best to find care for my grandmother in India. In some ways, we were lucky — we could afford to take her to quality medical facilities — at least by India’s standards. Hope still remained an option. Yet, after many failed attempts of targeting the new sources of pain, a metastatic tumor was found near her spine. Whether the clinicians had not been adept or did not have the proper diagnostic tools, it didn't matter — it was too late for any available treatment. Without further options nor quality and affordable palliative care, she returned from the urban hospital to her rural home to endure her last weeks and days in the company of her family.

With the anniversary of her passing, I've found myself reflecting on this difficult moment, leading me to share this story with you for a few reasons.

I'm glad the data has backed up this fact in recent years. Indeed, investments in women are the key behind progress on the Millennium Development Goals (MDGs). They are the bedrock for families, children, local economies, and entire societies.

Yet for people working on these issues for many years, this data is no surprise. What’s more shocking continues to be the lack of progress on MDG 3 - “promote gender equality and women’s empowerment”. In each of the key targets for this MDG - levels of girls’ education (particularly compared to boys), the share of women working in the non-agricultural sector, and the proportion of seats held by women in national parliaments - progress has fallen short. Today, 75% of HIV-infected youth in Africa are girls, 70% of the world’s out-of-school youth are girls, and pregnancy is the leading cause of death among girls aged 15-19. While I won’t go into details on all the indicators and targets in this post (you can read more about the targets at an official UN site), I wanted to focus on some promising momentum and highlight two important questions.

On a global policy level, recent years have seen MDG 3 (and relatedly, MDG 5 on women’s health) come to the center of development discussions in an unprecedented way. The Obama Global Health Initiative, for example, explicitly states a “women and girl-centered” approach to their implementation and strategy. Secretary of State Clinton has championed this in her public commentary on the Initiative. Over the past few months, several major meetings have focused on women, including the recent G8 conference in Toronto and Women Deliver in Washington D.C.

When we think about the places where policies influencing global health are debated and decided, there are a few usual suspects — cities like New York, Geneva, Washington D.C and London. Not surprisingly, though, and perhaps disappointingly, all of these cities are (1) in western, "developed" countries and (2) home to major international or national aid agencies (from the World Health Organization to USAID).

But as interest grows in tackling health issues in a more global way, alternative "hot spots" are proving that more players can participate — and that the practical operations and intellectual foundations of global health can be shaped in a manner more suitable to this emerging field. Here's a quick primer on where else to look for new ideas and influence:

Kampala, Uganda: Over the past fifteen years, Kampala (and particularly Makarere University) has been the site of many new collaborations in global health. Tens of universities with global health programs in the U.S., for example, have official collaborations with Makarere, and participate in mutual research, training and service programs together. Kampala has also been a central hub for the AIDS epidemic, providing critical lessons for the AIDS movement during the 90s. For example, Kampala-based Peter Mugenyi — AIDS pioneer and director of the local Joint Clinical Research Center — helped inspire President Bush's efforts to fight AIDS, and was even the first non-American to be the First Lady's guest during a State of the Union speech (in 2002, when Bush announced the President's Emergency Plan for AIDS Relief). And as donors have begun to scale back AIDS funding in recent years, Mugenyi has also become a vocal critic of Obama's cutbacks.

As if the debate over immigration reform wasn't tense enough, these days, U.S. public health officials are growing increasingly concerned about the possibility that undocumented Mexican immigrants are entering the U.S. with drug-resistant forms of tuberculosis. What's more, such officials believe that fear of deportation is making such immigrants reluctant to seek care for their illnesses — thereby spreading the disease. It's a volatile challenge that lies at the intersection of two controversial issues: U.S. health care and immigration policy.

There are multiple questions we need to consider here. To begin with, are undocumented immigrants more likely to carry multi-drug resistant tuberculosis? And if so, what’s the geographical source of their illness? I haven’t seen the latest data or evidence to answer these questions, but before making serious claims about who's carrying the disease and from where, we need to get the facts right.

But presuming that there's some basis for this concern, how should we respond to this challenge?

Some maintain we should deny health care to undocumented immigrants, who are seen as “drain” on the health care system. According to this theory, we should continue to spend billions of dollars building stronger walls to ensure that immigrants — and any pathogens they may carry — can't illegally enter the U.S.  During the course of the health care reform debates, for example, policymakers insisted that any reform ensure that undocumented immigrants wouldn't receive federally funded care. (Forget about the cost of potential epidemics created through lack of access to care, right?)

But there’s another way forward — one that involves reform of America’s immigration policies, as well as support of Mexico’s public health system.

When it comes to global health, talk of bed nets and anti-malarial drugs is common. But what about operating rooms?

A new study from Harvard researchers (including surgeon and author Atul Gawande) concludes that 2 billion people — or one-third of the world's population — lack access to basic surgical services. Not surprisingly, this access gap most affects the world's poorest. Of the estimated 234 million surgical procedures done each year, the poorest third of humanity undergo just 4% of procedures, while the wealthiest third account for 75% of them.

Given such shocking numbers, it's not surprising that the effort to provide surgical services to the poor has been called the “neglected stepchild of global health.” The reasons behind such neglect are quite obvious, if unsettling — surgical services requires highly trained staff and surgeons, a significant investment in infrastructure and ongoing access to equipment and tools. For decades, these necessities have been deemed too expensive and complex to provide in settings of poverty. There's no strategy like vaccinations and mosquito net distribution that can suffice. Accordingly, it's rare for foundations to support surgical services as a core funding area.

In the face of such limited support, what can we do?

Was this past weekend's G8 Summit a preview of September's major UN Summit on the Millennium Development Goals? If so, there's reason for deep concern.

The flagship program to emerge from the recent G8 Summit in Toronto was the "Muskoka Initiative," which commits G8 nations to an additional $5 billion in support of maternal and child health over the next five years. But instead of generating optimism, the declaration has been met with resounding disappointment.

Why? First, $5 billion over five years isn't even close to the target set by the Partnership for Maternal, Child, and Newborn Health, which estimates that aid of at least $4 billion per year is needed. Beyond the amount of the public pledge, there's also skepticism about whether such promised money will actually just be taken from other categories of development aid, and whether the U.S. Congress will even pass Obama's budgetary requests to back these minimal pledges. (For more concerns with the Muskoka Initiative, check out Sarah Boseley's recent blog post.)

However, there's a bigger (and more troubling) point here: if the G8 Summit is a barometer for how the world intends to deal with the MDGs, the verdict appears frighteningly clear — at a time when bold action on global poverty is required, G8 leaders are failing to step up to the challenge.

In the dense world of bureaucratic strategy and technical policy briefs, it's easy to get lost in alphabet soup and technical jargon. The Obama administration's Global Health Initiative — announced last spring — may be a critical step for U.S. foreign policy, but what does the six-year, $63 billion initiative really mean?

To understand what the White House is proposing, here's a quick primer to help you understand three of the initiative's top-used terms:

1). Country ownership: The GHI has made a point of increasing "country ownership" in the use and delivery of funding for health. The goal of giving governments more control over their programming is a praiseworthy one. Unfortunately, when it comes to eight of the countries recently selected for inclusion in the GHI (including Nepal, Malawi, Ethiopia and Guatemala), U.S. officials seem to be moving in another direction, arguing that such countries would benefit from more "management and technical support rather than funds."

Do countries really need more U.S. advisors to enhance their feeling of "ownership"? Seems like a dubious at best. As Mead Over writes, what countries really need is simple — budget support.

What's more, calls for country ownership don't jive with the fact that the Obama administration has broken its pledge to back the Global Fund for HIV/AIDS, Tuberculosis and Malaria, which supports countries in developing their own funding proposals (in contrast to such U.S. efforts overseas, which tend to promote U.S.-based organizations' work).

Perhaps you already know?

In the past week, the French model/singer-turned-First Lady has been trying to reach you with a key message about global health. Yes, you. In partnership with the Global Fund for HIV/AIDS, Tuberculosis and Malaria, Bruni's been spreading the word online about the Global Fund's new campaign: "Born HIV Free." Has it reached your monitor yet?

As aid budgets have started to sink amid the quicksand of the global recession, the campaign couldn't come at a more critical time. Even as the New York Times declares that the AIDS war is "falling apart," the Global Fund's effort hopes to reverse that tide. To catalyze a new surge of funding, the campaign features a snazzy website, a YouTube channel with videos narrated by Carli Bruni and made hip with Amy Winehouse tunes, a Twitter feed and a Facebook fan page.

Though the Global Fund works on many fronts — AIDS, TB and malaria — the campaign is focusing on an easy-to-digest goal with universal appeal: ending mother-to-child transmission of HIV. Is that message clear and simple enough to help a campaign like this go viral? Only time will tell. But in the meantime, it seems like a smart move.

It's an unprecedented one, as well. As Sarah Boseley writes, since its creation in 2001, the Global Fund has long considered its core audience to be heads of governments. Now, though, they're reaching out to another critical constituency: citizens that can push their leaders to make the right commitments.

It seems like every time I'm at a conference on global health or international development, "sustainability" is the buzzword on everyone's lips. I've often wondered, however, what does all this talk of "sustainability" really mean?

In a recent edition of Global Public Health, a group of authors (including Partners in Health founder Paul Farmer) challenge the "paradox of sustainability" that we've seen develop, and offer some useful new directions.

Here's what they tell us: While the concept of sustainability arose with good intentions — in response to lack of success with earlier forms of international aid — too often, the focus is now on sustaining organizations, rather than sustaining health. Focusing more on the latter, they argue, would mark an important but necessary shift for global health programs. You've probably heard the idea that donors and western NGOs should be in the "business of putting themselves out of business," or that they should build towards financially "self-sufficient" models. However, neither framework necessarily places the emphasis on the right "end game" — building enduring systems that sustain improvements in health. Such a mental leap can only start with funders, who need to squarely confront these questions of sustainability. They can start in three ways:

1) Take an inter-organizational strategy: Unfortunately, funders today place an undue burden on implementing organizations, who must show each and every grant cycle that their programs are financially sustainable. Instead of this "organization by organization" view, funders should take a broad view that spans an entire "ecosystem" of organizations and their many programs. They can encourage collaboration between organizations working in similar areas — and measure the success of a grant less in terms of whether an organization is sustainable, and more in terms of an organization's overall impact.

Last week, Jina shared the disturbing news that those testing positive for HIV/AIDS across the developing world are being denied treatment. The immediate culprit for this? The Obama administration, which decided in 2009 to essentially flat-line its funding of HIV/AIDS programs.

But another community which has to confront its role in this phenomenon are global health advocates, many of whom in recent years have questioned whether the AIDS movement has distorted health system priorities and taken money away from other critical issues. AIDS treatment activists have even been painted as "bullies," rather than allies — and vital leaders — in a broader movement. Unfortunately, the global health movement has failed to move beyond this false debate, which pits disease against disease. The result is that our overall ability to pursue a bolder, collective push has been diminished.

In the face of the recent news on AIDS treatment, how should the global health community — from maternal health advocates to health system gurus -- respond? It should be clear to all: In this critical moment, we need to respond to this challenge by locking arms with AIDS activists.

Perhaps the most obvious reason to lock arms is because people do not live their lives in separate programmatic areas. An HIV/AIDS patient may be a mother, a malaria patient, a child. The AIDS "backlash" does little to acknowledge these connections.