There is No Finish Line

 Who could not be absolutely in love with Gabby Douglas? With Alex Raisman, Jordyn Wieber, McKayla Maroney, and Kyla Ross…the Fab Five who won our hearts and medals at the Olympics?  Along with so many athletes we are watching intently, cheering for, sighing for, disappointed with and celebrating with, they are paragons of health, of beauty, of achievement, of competitiveness, of winning.  Even when they fall short (literally off of a balance beam) we know they are at the Olympics because they are the best in the world.

As I watch night after night in my bed, my bedroom being the only place I have a television (very small) and air conditioner (very noisy), I find myself wondering what it is that these young women and the other athletes at the Olympics have that has made them the great athletes they are.  Is it exceptional physical abilities, a drive and commitment to their sport, parents who devoted themselves and their children to rigorous training, some unknown Higgs Boson-like God particle that they were born with? (http://news.nationalgeographic.com/news/2012/07/120704-god-particle-higgs-boson-new-cern-science/)

I did a little very non-scientific research on “what makes athletes great?”  Here are a couple of results.  The first is from a New York Times blog for junior high students. This is an answer from a 13 year old:

 Okay a lot of things make athlete storng and those things can be by eatting good and also by trying there best.but most importantly is when they never give up  http://learning.blogs.nytimes.com/2010/02/08/what-makes-an-athlete-great/

This one is from an article in Shape magazine from a couple of days ago:

In my opinion, it’s not just the amount of medals you win or how many events you compete in. There is definitely a lot more to being an Olympian than that. I believe athletes like Wilma Rudolph and Jesse Owens epitomize what it means to be an exceptional athlete. Rudolph was born prematurely and spent the bulk of her childhood in bed. She suffered from double pneumonia, scarlet fever, and later she contacted polio. After losing the use of her left leg, she was fitted with metal leg braces when she was only six. However, years of treatment and determination to be a “normal kid” worked, and Rudolph was out of her leg braces at age nine. She went on to become a basketball star before taking the track and field world by storm and ultimately went on to win three golds and one bronze at the 1960 Olympics in Rome. From there, she became the fastest woman in the world and the first American woman to win three gold medals in one Olympics.  http://www.shape.com/blogs/london-2012-summer-olympics/what-makes-olympic-athlete-great

Never giving up and overcoming difficulties seem to be favored ingredients, and certainly we have seen that night after night.  Gabby Douglas actually did fall off the balance beam and got back on; she didn’t win a medal in that competition and she knew she wouldn’t win, but she got back on that narrow strip of hard wood and jumped and tumbled and vaulted off.

Two things were going on in my head as I was watching event after event and pondering the question of what makes these athletes great: they were perhaps more subliminal than rational thoughts.  One was the often-played snippet from the Phillip Phillips song, Home.

Just know you’re not alone, Cause I’m going to make this place your home

And there they were accompanied by the song: the women’s gymnastics team, the audience cheering, the parents, the coaches.  The Karolyis and Liang Chow literally going to the mats and challenging Alex Raisman’s score to secure her bronze medal on the beam. Win or a fall, you are not alone.

The other had nothing to do with the Olympics.  It was an article in the Sunday New York Times Magazine section from July 29 that I kept getting distracted from and kept being pulled back to.  The picture on the first page of the article, titled Hope in the Wreckage, was of two women who could not look less like Olympic athletes.  Claudia Cox, a visiting nurse is pictured kneeling on one knee at the bed of a women dying of bone cancer at home.  “Just know you’re not alone,” the lyrics seeped into my head.  But it wasn’t just the photo. Claudia Cox works in Jackson, Mississippi a place with some of the worst health outcomes in the country.  Sixty-nine percent of adult Mississippians are obese or overweight: at least 25% of the state’s households do not have access to healthy foods, adequate grocery stores being up to 30 miles away.  The article notes that many of these families buy their groceries at gas station convenience stores. Mississippi has the highest teen birth rate and Human Rights Watch calls the state “the epicenter of the H.I.V. epidemic in the United States.”  Tragic human wreckage indeed. So where was the Hope?  The Hope is Claudia Cox working for an organization called HealthConnect which was founded by Dr. Aaron Shirley and Mohammad Shahbazi, a professor at Jackson State University, based on the community outreach and very personal home care in a program in Iran. The Iranians founded “health houses,” local huts that contain exam rooms and sleeping quarters for community health workers in rural areas to reach the population living in more than 60,000 villages outside the urban areas of Iran.  The community health workers who are all from the villages themselves, “advise on nutrition and family planning, take blood pressure, keep track of who needs prenatal care, provide immunizations and monitor environmental conditions like water quality.”  The services of the health houses lowered rural infant mortality by 75% and substantially lowered the birth rate, two benchmarks of overall improvements in the health of a population.  Dr. Shirley, impressed with the positive impact on health outcomes in Iran, adopted many of the same services, mostly local community members/health workers establishing close personal relationships with patients, encouraging them, counseling them, advocating for them. In one year the services of HealthConnect cut the rate of admissions to Central Mississippi Medical Center by 15%. http://www.nytimes.com/interactive/2012/07/27/magazine/mississippi-health-care.html#

I have seen these same health strategies and relationships in the home visiting programs in Costa Rica, in Resource Mother projects in Norfolk, Virginia, in the MIRA project in Nepal.  Community health workers, peer educators, home visitors teaching, supporting and advocating which all comes down to what the best coaches do for the best athletes.

The positive differences in any of our lives are often the results of coaching.  I will never play tennis at the Olympics, I am not even seeded and I don’t play at an exclusive club, but I do have a coach.  Bill is the best; he knows just how to keep me improving and “playing up,” without my getting frustrated (although he occasionally slams one past me just to keep me humble.)  He is also a person who has been there most weekends through many of my life’s changes over the past 7 years.  I missed the opening ceremonies for the Olympics because I was out with two of my other coaches, my yoga buddies Lauren and Julie who have also coached me as friends and guides.  My daughters Kristin, Kierra and Alex keep me balanced and let me fall and are there to get me back up or just sit on the floor with me for a while.  Carol has been coaching me since I was 5. Heller An who is a triathaloner knows good coaching.  I am fortunate to have many wonderful coaches.

Sure we all have our gifts, we all have our challenges, our abilities and disabilities, and some very exceptional people to dazzle and inspire us in Olympic events.  They show us what can be.  So does Claudia Cox.  So do each of us when we refuse to give up, when we open ourselves to being coached and when we assure others that “you are not alone.”

Home Phillip Phillips

or

http://www.youtube.com/watch?v=7dfTURAhrTY

Hold on, to me as we go

As we roll down this unfamiliar road

And although this wave is stringing us along

Just know you’re not alone

Cause I’m going to make this place your home

Settle down, it’ll all be clear

Don’t pay no mind to the demons

They fill you with fear

The trouble it might drag you down

If you get lost, you can always be found

Just know you’re not alone

Cause I’m going to make this place your home

Settle down, it’ll all be clear

Don’t pay no mind to the demons

They fill you with fear

The trouble it might drag you down

If you get lost, you can always be found

Just know you’re not alone

Cause I’m going to make this place your home

I heart H20

 Summer of 2012

It has been hot.  Temps have risen to those dreaded triple digits in New York, in Chicago, and places where the corn should be as high as an elephant’s eye, but is now dried up and inedible.  Even here in my little village of Piermont on the Hudson where there are usually lovely river breezes, my grass is scorched and the petunias I planted along my driveway have wilted beyond any vegetal recognition.  Writing at my computer or commuting into New York for meetings in the heat I have been reminded of an experience I had in the heat of last summer when I traveled into the Bronx every day.  The following was written late last summer with my love for water and my eternal love for the Bronx.

Summer 2011

I love water.  I drink it out of faucets, coolers, fountains, my backyard hose and as snowflakes on my tongue.  I love to be in it in rivers, streams, oceans, pools, my pond, stomping in mud puddles in my Wellies. I love to be on it in sailboats, kayaks, canoes, ferries, big truck inner tubes.  And really I just love to look at it and listen to it.  To me water just looks and feels and sounds like life itself: the trickle of a waterfall just melting after a winter freeze or the crashing of a wave.

This summer in New York was a hot one.  And so perhaps we all became a little more aware of water than we usually are.  People complained about the humidity while gulping from plastic bottles of Poland Spring or Deer Park or Jennifer Aniston’s Smart Water.  Leaving work via the streets of the Bronx I would have to close my sun roof and nudge through the powerful spray of an open hydrant and the children and adults soaking up the blast of cold water.  Concerned about kids and their parents coming to our child center who had traveled on subways and buses and hot sidewalks I ordered cases of bottled water and asked all staff to make sure everybody got water to drink when they arrived, while they were at the center and bottles to go.  And yes I worried about the plastic getting warm and releasing toxins and taking eons of time to degrade but it was a matter of situation ethics.  Gotta get water into every man, woman and child.

Some time in late July an email popped up on my computer screen from an organization called End Water Poverty http://www.endwaterpoverty.org/  It contained a message requesting donations which seemed quite compelling with a statement, “Our ambition is massive.”  Massive ambition indeed and massively needed for there in the opening paragraph was the statistic that to this day causes me to have to catch my breath every time I find myself taking those bottles, and cups and sips of water for granted:  every day 4,000 children die from drinking dirty water.  That is 1,460,000 children a year, a massive number of very special, lovely individual children who die because there is no clean water for them to drink.

Water.org with the leadership of Matt Damon cites these statistics:

780 million people lack access to an improved water source; approximately one in nine people.

3.41 million people die from water, sanitation and hygiene-related causes each year.8

The water and sanitation crisis claims more lives through disease than any war claims through guns.

People living informal settlements (i.e. slums) often pay 5-10 times more per liter of water than wealthy people living in the same city.

An American taking a five-minute shower uses more water than the average person in a developing country slum uses for an entire day.

Take a look at their website; they have a very beautiful video (with very beautiful Matt Damon.) at http://water.org/

The heat has somewhat subsided although midday it can still get oppressive on the sidewalks of the Bronx.  Yesterday I had to run back and forth a few times between  the medical center and my advocacy center.  I had patients and budget issues and the next meeting to go to on my mind, but most prominent in my consciousness was the aching in my sweaty wet feet as they rebelled against the cute kitten heels and pointed toes of the shoes I was wearing.  “Ah, when I get home I’ll dangle my feet in my pond,” I was thinking as I looked up and saw, through the shimmering heat waves, what seemed to be an aparition in the desert approaching me.  She was tall and elegant swathed in red and orange, the scarf of white wrapped over her dark brown face.  It wasn’t until she was about 10 feet away from me that I could see that she looked exhausted, beads of water on her forehead, streams running down her face, her eyelids lowered.  She reached out to me and I realized that we were both fortunate enough to be next to the front steps of a house under the shade of a gingko tree.  Her name was Ann and she was on her way to the bus stop on Bainbridge and 210th Street.  I asked her if she would like to come into my office for a while but she said she had to get to the bus and home to her apartment where her grandchildren would be arriving after school.  As we shared a grandmother moment, I remembered that I had stuck a bottle of water in my briefcase and I pulled it out and offered it to her.  She tipped her beautiful head back, closed her eyes, took a drink and smiled and then I remembered a line from The Little Prince:  “This water was indeed a different thing from ordinary nourishment. It was good for the heart, like a present.”

The gift to me from Ann was a moment of rest under a gingko tree when I could slip off those shoes, two women sharing our love of our families, her smile and a reminder that we all need water to sustain us and keep us massively ambitious.

Summer 2012

No matter where I am, I will always send my love to the Bronx

(photo credits: Jon Cary: 104 in Chicago. Lois Pearlman: Snow in the Bronx.)

When Sunny Gets Blue: Sex on the Beach, Mosquitoes and Karen Silkwood

There are lots of songs about being blue, in fact of course a whole genre of music is called The Blues.  “I Guess That’s Why They Call It the Blues,” “Blue Moon,” “Blue Christmas,” “Blue Velvet,” “Blue Hotel,” “Don’t It Make My Brown Eyes Blue,” “Love Is Blue,” “Tangled Up In Blue,” and “Mood Indigo.”  Blue in a song usually connotes sadness, but of course “When Sunny Gets Blue” took on a whole other connotation after Klaus von Bulow allegedly poisoned his wife Sunny putting her into an irreversible coma.   Sometimes being blue is literal and dangerous.  But enough about me; I can write about that in a future blog post sometime.

Blue has lately been making quite a fashion statement in nail polish colors:  Blue Blowout, Navy Narcissist, Blue Freeze, Poolside Passion, Blue Rhapsody, Beach Bum Blue, and Sex on the Beach (honestly, I don’t think Sex on the Beach is blue, but I did think it would get your attention.)  Sometimes at the nail salon I simply marvel at the names of nail polish colors and wonder who gets paid to make them up.  What an amazing job that must be.  I usually go with something like Gucci Mucci Pucci, Tennis Corset,  Angel Food or Negligee, but I am pretty conservative about my nail polish colors, only an occasional foray into something like Fishnet Stockings, Berry Naughty, Affair in Red Square, Skimpy Bikini or Clutch Me If You Can.

I love getting my nails done: the soaking, the filing, the hand massage and the little back rub as my nails dry.  Oh my God! And then there are pedicures…..And you know what?  I love the women who do my nails at the little shop I have gone to for years in Closter, New Jersey called Lux Nails.  As they file and massage and polish we have gotten to know each other.  We talk about our relationships.  The holidays.  Vacations.  We talk about our kids.  I have met their daughters and they have met mine.  I have had my nails done for celebrations, professional events and sometimes when I have been sad and blue, because the women bonding in the salon is very comforting.

So in no way is the following information meant to discourage anyone from enjoying their mani/pedis or abandoning their favorite salon friends.  I do think we all need to get some information about the products that are used in our nail salons.  I got some at a very interesting information at a forum I attended sponsored by NYCOSH (New York Committee for Occupational Safety and Health) called Beauty at What Cost?  Hazards Associated with Exposure to Beauty Care Products on June 20, 2012.

Here is the issue in brief: there are some really hazardous chemicals in those lovely nail polish colors and the other products used in nail salons.  In addition to various other chemicals, there is what is referred to as the toxic trio:  toluene, formaldehyde and dibutyl phthalate which are all quite prominent in nail polish,polish removers and artificial nail products.  They cause breathing difficulty with asthma-like symptoms, headaches, dizziness and have been associated with cancer and kidney disease.  All of these of course should be totally avoided during pregnancy.

For those of us who go to have our nails done once a week, every two weeks, whenever we want to feel good, the effects are most likely a non-factor in our health (but ask your obstetrician if you are pregnant.)   For the women who work in salons, our dear friends with whom we chat and sometimes share our deepest secrets, the health effects can be dangerous, deadly.

There are safety precautions that can be taken:  ventilation is really important.  Your salon should have good exhaust fans, windows, vents to remove the chemicals from the air.   Chemicals should be labeled.  And long sleeves can keep chemicals from getting into exposed skin.  With harsh chemicals gloves should be worn.  Here’s what it says in a Health Hazards brochure from OSHA:  Most work in nail salons will not require respiratory protection:  good ventilation and good work practices should keep exposure to gases, vapors, and particulates to a minimum.

So next time you have your nails done, you might just want to look around the salon.  You don’t have to be the Salon Police and you certainly don’t want to hassle the workers.  You might just want to make some suggestions or ask a few questions.  You can get the Safety and Health Topics at http://www.osha.gov/SLTC/nailsalons/chemicalhazards.html

Don’t we just love the women who so caringly do our nails, massage our hands and talk to us even when we are blue?

As women we all deserve to be beautiful and healthy.  All of us should be able to enjoy Safe Sex On the Beach.

 

Mood Indigo:  Duke Ellington   http://www.youtube.com/watch?v=GohBkHaHap8

 

Or you might like the Harlem Ramblers http://www.youtube.com/watch?v=Akd7F_w0als&feature=related

 

And here are the lyrics by Ella Fitzgerald:

You ain’t been blue, no, no, no

You ain’t been blue till you’ve had that mood indigo

That feelin’ goes stealin’ down to my shoes

While I sit and sigh, “Go ‘long blues”

Always get that mood indigo

Since my baby said goodbye

In the evenin’ when lights are low

I’m so lonesome I could cry

‘Cause there’s nobody who cares about me

I’m just a soul who’s bluer than blue can be

When I get that mood indigo

I could lay me down and die

You ain’t been blue, no, no, no, no, no

You ain’t been blue till you’ve had that mood indigo

That feelin’ goes stealin’ down to my shoes

While I sit and sigh, “Go ‘long blues”

 

Mosquitoes and Karen Silkwood coming soon to a computer near you in my future blog posts. 

Stay Tuned!

 

 

 

 

To Be or Not To Be (an organ donor)?

If you don’t have a uniform donor card or you don’t know where it is and you haven’t designated organ donation on your drivers license, here’s the link to register.  http://www.thenationalnetworkoforgandonors.org/become-a-donor.html

You don’t need to take your organs to heaven.  I have it on really good insider information that you are not going to need them there.  So please stop reading right now and do the donor thing.  Thanks!

Now there is another kind of organ donation that can be provided without having to wait until death.

On February 18, 2012, there was a very compelling article in The New York Times http://www.nytimes.com/2012/02/19/health/lives-forever-linked-through-kidney-transplant-chain-124.html?pagewanted=all

At the top of the page is a collage of 60 photographs of individuals.  They are kidney donors and kidney recipients.

As it turns out, a little fluke of our human evolution is that we really don’t need both of our kidneys.  That’s the good news.  The bad news is, even though we all have two, one is not a back up for the other.  If one goes bad, they both go bad and the choice then is long days attached to a dialysis machine to clean out your blood (which is what kidneys do) or death.  Or, that third amazing miraculous possibility:  a transplant.

Most transplants are in fact from deceased donors, the kidneys and other organs “harvested” while the heart is still beating, but the person has been declared dead.  I know this is scary sounding stuff, but there are rigorous medical, legal and ethical regulations assuring that no is put at risk or compromised or taken advantage of.  It is of course a very emotional time for family members, which is why I strongly encourage you to take care of your donor wishes long before anyone has to grant them when you die.  There are many very moving stories about tragic deaths followed by inspiring lives saved by transplants.

The NYT article though is about live donors.  It is typical for live donors to be family members or friends of the recipient.  Both operations take about 3 hours and recovery is a couple of weeks.  But often there is no one in the family who is an exact match.  If this is the case, then the would-be recipient becomes one of 90,000 people who wait on a donor list for a kidney from a deceased donor.  Fewer than 17,000 people receive a kidney every year from the list and about 4,500 die waiting.

If there is no match among family and friends, there is one other option to just waiting on the donor list.  There is a way of making all those mismatches actually work and save lives.  According to the NYT article what it takes is one anonymous donor to start a chain of matching from the jumble of mismatches.  One person who has no connection to anyone who needs a kidney, just gives one up.  In the chain depicted in The Times, it was one guy, Rick Ruzzamenti, in Riverside, California.  He donated his kidney to anyone who would need it, a total stranger who was a match.  Someone in that total stranger’s family donated their kidney to another total stranger who was a match.  Someone in that recipient’s family donated their kidney to another total stranger…and on and on it went…..30 kidneys, 30 lives saved.  Miraculous.

Live donation is not dangerous, but no day at the beach either.  You have to really want to do it…you have to be able to take time off from work. You need someone to take care of you when you leave the hospital.  And of course because organs can in no way be “sold,” there is no compensation, except free medical care for the procedure.  I’m not sure this is even a matter of being brave; maybe as was written about Rick Ruzzamenti, it takes being a little crazy, although to be a live donor you are required to go through successive psychological testing.  Mr. Ruzzamenti’s wife even threatened to leave him (she didn’t and lovingly curled up with him in his hospital bed as he recovered.)

I must say I read this article over and over and over again.  I went online and read about the procedure and the risks and down loaded the consent forms.  I had lots of accrued sick time although I don’t think I could have used it since kidney donations are elective procedures.  I am not a brave person and I don’t think I could have done it, but I did fantasize a lot about it.  Then two things happened.  I left the hospital where I was working…and all that paperwork sat on my desk.  And then something else happened at that same hospital.  The sister of a dialysis patient was donating a kidney for him.  He had been on the waiting list for two years and she was a match.  She winked at him as they were wheeled apart for their separate but perfectly orchestrated procedures.  And then she died on the table….an unexplainable slip of a scalpel severed her aorta.  She bled to death before she could be saved and before even one of her kidneys could be saved to save her brother.

The statistics for live kidney donation indicate that the procedure is very safe.  Only a chance of 3 in 10,000 people die as a result of the procedure.  But there are the statistical 3 and Yolanda Medina was one of them.  Tragically her brother is still waiting for a kidney….maybe there will be an anonymous donor since he is way down on the donor list and could have to wait for years, if he has that long to live.

Please share this information about live donors.  There may be someone who knows someone who knows someone who knows someone who like Rick Ruzzamenti will say, “Take my kidney, please!”  It might be someone a little crazy, or very egotistical, or spiritual, or who knows what motivation, but it could be someone who can start a chain of miracles.  Not all of us can do it but maybe we can be messengers.

Maybe there will be that anonymous donor….maybe not.

But as e.e. cummings wrote, “miracles are to come, with you i leave a remembrance of miracles.”

Of Health and War

Last Monday was Memorial Day, the day that extends a weekend to three days, celebrates the beginning of summer and commemorates those who have died in wars with ceremonies, parades and poppies sold at grocery stores.  In my small town USA village of Piermont, New York, there was the annual parade through our little town to the Veterans Monument.  I had played tennis early in the morning and was returning just as our Piermont Police Department was starting to close the main street with saw horse barricades diverting cars through the pier parking lot.  After a quick handshake through my car window with my favorite Piermont cop, I took the detour, arrived up the hill at my house and grabbed my bicycle (oh, yes, got out of my sweaty tennis clothes and slipped into biking shorts.)  I cycled down to the Veteran’s Monument and got a good spot for the parade which consisted of the Fire Department volunteers in their uniforms, the very impressive Piermont (“on-the-Hudson”) fire trucks, our Mayor, and the Yonkers Pipe and Drums Band wearing kilts.  And, there were several veterans of wars marching, elderly gentleman who I would guess had been in WWII.  There were a few speeches and prayers, the band played “God Bless America,” it was over, and the crowd dispersed.

There was also another Memorial Day event that was taking place out at the end of the pier.  Every year on Memorial Day a huge bonfire constructed with enormous tree trunks is built right on the river.  It is lit at midnight and burns through Memorial Day until midnight and then is bulldozed into the river.  It’s a pretty impressive site for our little town.  It’s called a Watchfire, a homecoming fire.  It is a blazing light in the dark night to welcome back all of the souls lost far away and to bring them back home.

While all this was going on, and people were stoking their barbeques, I was thinking about all of those wars, all of the lost and damaged lives.  In fact I Googled “US in Wars” and opened up a chart that you can access on Wikipedia.  There was much more information than I expected.   In the meantime I couldn’t help thinking about other “wars.”  The war on poverty…who and what are we exactly fighting?  Was there a beginning?  Will we win or will poverty win?  The war on drugs.  The war on crime.

The war on cancer was declared 40 years ago by Richard Nixon.   Here is an interesting commentary. http://odewire.com/52324/the-end-of-the-war-against-cancer.html

And in an updated report from 2010:

Declaring a “war on cancer,” President Richard Nixon signed the National Cancer Act on Dec. 23, 1971, in a White House room full of happy scientists and proud politicians. The bellicose metaphor implied that cancer was one enemy and that victory was possible. Nobody believes that anymore. It would have been no less naive if Nixon had declared a “war on bad government” that day, ignoring the fact that there are a hundred ways to govern poorly and no single way to do it right.   For the full article: http://www.washingtonpost.com/wpdyn/content/article/2010/04/26/AR2010042603361.html

There of course has been a war on AIDS: http://www.nytimes.com/2010/05/14/opinion/14fri2.html

Brian Lehrer on WNYC has been conducting a survey called “End of War” asking the question “Is War Inevitable?”   http://www.wnyc.org/shows/bl/series/end-war/

Many responses indicated that if more women were in power that more wars would be prevented because women are more inclined to negotiation, conflict resolution, and a focus on health and well-being for themselves and their families.

Former Chilean President Michelle Bachelet, the first Under-Secretary-General and Executive Director of UN Women, discussed the role of women and war–and the importance of having more women in power to lessen conflicts around the world.

An interesting connection, or perhaps it is the disconnection, of war and health is in the little Central American country of Costa Rica.  In 1991, after having researched the substantial decrease in infant and maternal mortality and increased health and well being of children and families based on the Costa Rican home visiting program, I traveled to San Jose and had a meeting with Dr. Lenin Saenz, one of the architects of the government-funded health care program.  The program included visits to every family in Costa Rica four times a year to assure that all children had their vaccinations, that pregnant women were receiving prenatal care, that the family had clean running water and everyone was in good health.  The visits were done by community health workers who had been soldiers in the war against mosquitoes.  Yes, the war against mosquitoes was mounted by a collaboration between the United Fruit Company and the Costa Rican government.  So many farm workers were dying of malaria that the fruit export business was suffering.  Literally armies of mosquito eradicators were employed in the joint effort.  By the late 1960’s, the mosquito was defeated and Costa Rica was free of the tyranny of malaria.  But now what to do with all of these people who had visited every part of the country spraying and removing breeding areas?  Dr. Saenz and his colleagues in the Costa Rican government decided to fight on…this time against infant mortality, maternal mortality, water borne diseases, and just for good measure, illiteracy.  They retained the army of workers and re-educated them to be home health visitors.  Within 10 years between 1970 and 1980, the health status of Costa Rica dramatically improved as indicated by the drop infant mortality by 69 percent from 61.5/1,000 to 18.6/1,000. How did they finance this one might ask?  All those health workers fighting disease.  Well, they used money that other countries use to pay for their military.  Costa Rica in 1948 had decided not to fight their own people or other countries; they disbanded their army.  Since the mid 1980’s there have been financial challenges that have impacted the success of the Costa Rican war against disease, but there is still no military and the health status far exceeds that of most countries in the world.

So Is War Inevitable?

This post does not have neat clever ending or political message or even health prescription.  I just find myself wondering if the question needs to be shifted from “Is War Inevitable?” to “Who or What Are We Fighting?” or more importantly,  “Who Are We Fighting For?”

As for Memorial Day, I continue to think about the Watchfires bringing everyone home.

Battle for the Breasts: Got Milk?

There was an op-ed article in the New York Times last week that seemed like deja vu all over again.  Titled Maternity Swag, the author noted the current practice of infant formula companies providing samples of formula to hospitals for distribution to mothers as gifts to take home with them.   The justification of hospitals is that they benefit from providing this free advertising by receiving support from the companies for their neonatal intensive care units, nurseries and lots of gratis equipment.  Hospitals claim they are giving the samples to women because so many women are having to return to their jobs shortly after giving birth, and they need the formula to feed their babies while they are away from them at work.

I actually became aware of a global tragedy due to the very unethical business practices of formula companies in the early 1970’s as I was about to have my first baby.  Researching the benefits of breastfeeding, I came across information about the Nestle infant formula campaign in developing countries.  With a decrease in infant formula sales in the United States and countries in Europe as more women chose to breastfeed their babies, Nestle stepped up their marketing of “breast milk substitute” in Africa.  The marketing strategy included sending company salespersons wearing white uniforms into local hospitals in Africa and giving women samples of about a month’s worth of powdered formula….enough so that by the time they ran out of the sample they had also lost their breast milk and had to buy the formula.  But the formula, the mothers soon learned, was very expensive, a month’s worth often costing more than the family income for a month. And so the formula that was purchased was watered down and often with unclean water. The number of babies who died cannot be calculated, but the World Health Organization had to spend million of dollars to try to rescue babies and a generation of sick children.  It was perhaps my first small public health effort to demonstrate against Nestle in my local grocery stores to raise awareness of what the company that made chocolate milk for our kids was doing to mothers and babies in Africa.   Back in those days before computer generated labels, I had little handwritten notes that I stuffed in the shelves of chocolate bars and cocoa that read, “Nestle Kills Babies.” Today I guess I could provide websites and blogs and links to research, but back then the message was simple.

That was 40 years ago but UNICEF still estimates that a non-breastfed child living in disease-ridden and unhygienic conditions is between 6 and 25 times more likely to die of diarhhea and 4 times more likely to die of pneumonia than a breastfed child.  I suggest that any maternal and child health advocate take a look at this issue on the internet.  Maybe we still have to be in grocery stores protesting and questioning the business practices and marketing strategies that put our babies and children at risk of death and disease.   But maybe we need a more complex solution and protest.  Now as back then the issue is not just one of formula companies marketing their products.  The companies are just capitalizing on the political issues and governmental prorities that contribute to women being unable to breastfeed their babies for as long as they choose.   For example in the US there is simply the issue that many mothers do not work in “breastfeeding-friendly” workplaces as in the article below:

Every year roughly four million women give birth in the United States, and more than 75 percent of them choose to breastfeed. But with two-thirds of today’s working women returning to work within three months of giving birth, a lack of supportive workplace policies and laws is forcing too many nursing mothers to quit breastfeeding (or never start). Study after study has shown the value of breastfeeding in protecting both mothers and children from a number of acute and chronic diseases and conditions. It is time for our nation’s workplace policies—and our laws—to eliminate the barriers that keep many working mothers from breastfeeding.

Supportive Workplace Policies Critical for Nursing Mothers

www.nationalpartnership.org/site/…Mothers_Fact…/574216797?…

What Moms Need for Successful Breastfeeding After Returning to

www.med.umich.edu/whp/…/breast-feedingreturn-to-work.htm

In developing countries as well, some women need to go back to work, care for other children, and leave their babies for periods of time with other caregivers.  They may tragically be too sick and malnourished to feed their babies. And there is the lure away from breastfeeding that still comes from providers of infant formula supported by hospitals and health care providers who all profit from the sale of the formula and promote it as the way women can best feed their babies and be modern.  These are all opportunities for the formula companies to successfully market their products, but in farness to them they didn’t create the poverty that results in women not being healthy enough to breastfeed their babies or the other demands and stressors in women’s lives.

When I was 39 years old and gave birth to my youngest daughter, I breastfed her from birth during my maternity leave from my job.  She was born on Memorial Day and I was due to go back to work right after Labor Day, the day that celebrates workers rights and of course ironically is the same word as giving birth.  During the summer I actually had to go into my office in the Bronx to handle some contract budgets and also wanted my staff to meet my lovely baby, but I also took her with me so I could feed her.  I sat at my desk and breastfed her with the door closed.  Staff  were respectful but also embarrassed that I, the boss,  was “exposed.” Our family traveled to Barbados for an end of summer vacation and I still remember clearly sitting in a chair looking out at the sea contentedly rocking and feeding my sweet baby girl.  It was bitter sweet though because I knew that in a couple of weeks I was going to be spending 9 to 10  hours a day out of the house at my office away from her.  Yes, I look back now and think I could have pumped during the day at work, I could have frozen milk, I could have continued to breastfeed her at night with the baby sitter giving her my milk during the day.  But there was no “lactation room” where I worked.  I often had to be out of the office at meetings at other sites in the Bronx or in Manhattan…and mostly I felt I had to convince the people I worked for and worked with that having a baby had not in any way impaired my ability to be productive.  A few days after I went back to work Alex and I rocked together in her white wicker rocking chair and that was the last of our breastfeeding relationship.  I don’t think it in any way has impeded her health or our wonderful mother/daughter relationship and I had been able to breastfeed for about 3 months, but especially when I do this research about the benefits of breastfeeding I regret that it did not go on for longer.  I was 39 and working and my maternity leave was over.

The formula companies continue to claim that their distribution of free samples to women around the world is about empowering women so they can chose which feeding method or combination is best for them and their babies, but as the author of the NYT article states, “it drives up sales.”  Companies and organizations require that their employees to come back to work and there is little compensation in the United States during a Family Leave if one chooses to stay out longer.  Governments have other priorities besides ending poverty and gender inequity and lack of education for women and girls.  The formula companies will go on driving up their sales as long as women are not truly empowered to make the best health choices for themselves and their children.

So let’s join together and battle for the breast!

Maternity Ward Swag – NYTimes.com

www.nytimes.com/2012/05/11/opinion/maternitywardswag.html

 

Community-based strategies for breastfeeding promotion and support in developing countries: World Health Organization

http://www.who.int/maternal_child_adolescent/d s/9ocument241591218/en/

Nutrition – Protecting, promoting and supporting breastfeeding

www.unicef.org/nutrition/index_breastfeeding.html

Footnote or perhaps better called a breast note:

The May 21, 2012, cover of Time magazine featured a photo of a woman breastfeeding her three year old son.  This has caused quite a controversy about how long breastfeeding should last.  Join the discussion.  Send a comment to this blog!

Commentaries on the Time magazine cover

http://www.slate.com/articles/news_and_politics/explainer/2012/05/time_magazine_breast_feeding_cover_how_nursing_worked_in_prehistoric_times_.html

http://www.time.com/time/covers/0,16641,20120521,00.html

Heart Smithing

My friend Lauren has the most amazing business.  She sells hearts.  Yes, hearts, and her company is aptly called Heartsmith.  On her website are tiny little lockets, big exotic lockets, sterling silver, gold plated, white gold, yellow gold, simple, encrusted with diamonds.  Hearts for love, for romance, for family, for comfort, for remembering.  Hearts that can be engraved and filled with pictures of loved ones, little ones, dear ones departed.  I have bought some of these hearts for family and friends, and have been honored with a few that Lauren has given to me as gifts.  I have a lovely one engraved with my grandson Nico’s name and birthday, the same day as mine.  I gave one to my daughter Alex when her beloved cat Simon died.  Lauren actually named one of the lockets after me!  The Karel Amethyst locket and I gave one to each of my daughters and my granddaughter.

As you can probably imagine there are times of the year when Lauren is deluged with orders.  Well, of course Valentines Day.. but also  Christmas, Easter, wedding season (meaning June-ish,) and Mothers Day, which is approaching this week.  So Lauren is taking orders on the phone, picking them up online, helping people with their choices and getting those “when can you get it here?” last minute orders.  Knowing how busy she is this week, and having some unexpected time off myself, I offered to help her at her little shop/office where the magic all takes place.   I was there for about 4 hours yesterday and it was quite an experience.

First, having worked in the health care field most of my adult life, it was wonderful to be in a place where the decisions were about what would just make someone happy and feel loved.  I listened to Lauren as she talked on the phone to adult children and grandchildren, to husbands, boyfriends, and partners.  She advised on the kind of locket, the design, what would engrave well, what lockets would hold enough pictures for all the children, and she said things like, “oh that’s lovely,” “i love you..all lower case,” “how thoughtful,” “that picture of your daughter is beautiful!”  Here’s the thing..she wasn’t just selling pieces of  jewelry, she was helping people express their love.

In the meantime, my tasks were not so easy for me.  Being accustomed to writing reports and funding proposals, framing public health policy issues and advocacy, presenting at conferences with power points, I was all thumbs with slipping hearts into lovely little velvet pouches, confused by the various types of mailing packages, and a little challenged by the computerized packing and tracking program.  But as the afternoon went on, I began to really feel accomplished.  I even figured out how the make sure the pictures were inserted in each locket (they were…every one of them!)  And as I mastered these tasks I was able to feel a part of a wonderful love aura that was streaming out from the little shop in Haworth, New Jersey to California and Puerto Rico, to Argentina, to Swansea Wales, to Texas, to New York, to Mothers.

During the afternoon, Lauren mentioned to me that she had had an order for about a hundred tiny little gold lockets from a government agency that had funded a young mothers’ parenting program.  Rather than just giving these young women a certificate when they finished the classes they each received a little gold heart to remind them that the most important part of mothering, of good parenting is loving and being loved.  These parenting training programs like one I had overseen in a previous job, are skill-building opportunities, sometimes required by child protective services for women to be able to regain custody of their children.   There are usually sections of the curriculum devoted to early childhood development, to constructive (no hitting) discipline, stress reduction, nutrition, safety, like covering electrical outlets, holding hands when crossing the street, wearing bike helmets, making sure that cleaning solutions, pharmaceuticals, and sharp objects are out of the reach of small children.  The importance of talking to kids about drug use and keeping that dialogue open.  And as children become teenagers, having some of those very tough conversations about sex.  The parenting programs are all about helping parents keep their kids safe and healthy, reducing parental stress, and forming the bonds between mothers and their children that nurture what contributes most to the health of mothers, the health of children…love.  How brilliant for a project director to have decided to support that message by giving parenting class graduates little lockets.

As is evident in A Private Life in Public Health, my expertise has been in preventing child abuse, in helping to reduce maternal mortality, in child death review, in health care quality assurance, in promoting women’s empowerment.   For an afternoon, in a cozy busy little shop I was able to be a part of a process that was just good for people’s hearts, including mine.

To all of you Moms out there, Happy Mothers’ Day!

 

 

 

 

 

 

For a review of US government funded parenting demonstration programs

http://www.childwelfare.gov/pubs/candemo/candemo.pdf

For lockets

www.heartsmith.com

For a beautiful song Patty Griffin “Heavenly Day”

 

Moving Mountains Power Point

BASPCAN_Belfast

This link will download the power point I presented at the British Association for the Study and Prevention of Child Abuse on April 16, 2012 as referenced below in the post The Tragedy of Icebergs.

The Tragedy of Icebergs

Sunday, April 15, 2012, was the 100th anniversary of the sinking of the Titanic, the disaster that caused more than 1500 deaths and resulted in myriads of books, songs, and movies.  The current re-release of the James Cameron 1997 Titanic in 3-D is the highest grossing film in history.

Coincidentally (or maybe not so coincidentally) on April 15, 2012, I was in Belfast, Ireland where Titanic was built.  I was there for the British Association for the Study of Child Abuse and Neglect (BASPCAN) Congress to present on a project I have developed called Moving Mountains.  All over Belfast were reminders that this was the original home of the ship that was built to be unsinkable.  There was a model made of balloons in the Victoria Mall, pictures of the ship on feather banners hanging from lamp posts, various menu items (unsinkable baked potatoes and Titanic ale,) and signs that read, “She was all right when she left here!” implying that the workers of Belfast had done a fine job building her and someone else was responsible for wrecking her.  Then there was the Titanic Experience, with ads touting, “inside, the state-of-the-art exhibits make you think you’re part of the maiden voyage.  Don’t panic.  You aren’t.”

I must say I found the museum quite interesting with even an amusement park-like ride that takes you through the construction process in the belly of the ship.  One oddity, however, that my daughter. Alex  (who came along to the conference and then subsequent jaunt out to the west coast to Doolin with it’s fine pubs, music and ever flowing Guinness) and I discovered was that in the digital reenactment of the sinking, the ship tips up, stern to the sky, slightly twists and then slips silently under.  I think we all know that the ship actually sank about three quarters under and then split between stack 3 and 4 with the two pieces, bow and stern sinking separately.  Asking staff at the museum why this was not depicted correctly we were told, as if no one else had noticed, that seeing the ship break apart might be too upsetting for people.   Hmmmmmmm 1,500 people dead, but a digital reproduction of the ship breaking apart might be too upsetting?

This then is the story of a ship, but what is the story of the iceberg?  The exterior of the museum actually looks like it could be either the Titanic or the iceberg.

This makes me wonder about the iceberg that was just a piece of nature, beautiful glittering ice floating like a moving mountain on the sea, and like the ship, a massive traveler in the north Atlantic.  Icebergs are composed of freshwater and therefore are slightly less dense, 8/9s the density of seawater so only 1/9th of the ice is above the water surface.  After breaking away from a glacier,  bergs flow along, most of their mass and importance  unseen as they are carried by the Gulf Stream into warmer and warmer waters  to slowly melt and disappear entirely.  Unless there is a tragic meeting with a ship, they are doomed to be 90% unnoticed, unrecognized, undetermined.  So the phrase “tip of the iceberg” has flowed into our vocabulary, meaning there is ever so much more than meets the eye.

So meanwhile back at the conference, along with many other professionals including two of my dear friends/colleagues, Linda Burnside, founder of Avocation in Winnipeg, Canada, and Theresa Covington, Director of the National Center for Child Death Review, I was a workshop presenter.  My presentation titled Moving Mountains:  Enabling Children, Disabling Child Abuse was based on several years of research and project development to provide child abuse identification and treatment for children with disabilities.  Early research in the field of child abuse prevalence determined that children with disabilities were abused at approximately twice the rate of typical children.  Later studies reported that the rate was much higher, at least 4 to 10 times the rate of typical children, very difficult to identify and determine.  Working in the field of child abuse treatment I found that often referrals of children who had been abused did not include information about their disabilities and often children with disabilities were not referred for child abuse evaluations.  Children with disabilities who were abused were so often not identified, not treated, not believed, not listened to, not recognized; they were submerged deep in that unseen iceberg, only the tip noticed and helped.  Reaching children with disabilities is challenging.  Like typical children they are usually abused by people they know and who care for them; kids with disabilities just have so many more caregivers and people they have to depend on for their day to day activities.  The challenges of identification of abuse of children with disabilities and their ability to disclose are myriad.  In addition, the justice system discounts the testimony of children particularly with cognitive disabilities; like children under the age of 5 they are usually not considered credible and swearable and cases can only proceed if there is a witness or corroborating evidence.   So the abuse and deaths go unnoticed, unrecognized, undetermined.

After the Titanic sank and the International Ice Patrol was formed in 1914. several pieces of legislation were passed to assure that passengers on ships were safe:  a requirement for ships to check the Ice Patrol’s iceberg sightings, carry enough life boats, avoid ice fields.  Since the deaths of 1,500 people of the Titanic, there have been no other sinkings of ships and loss of life due to collisions with icebergs.  In the U.S alone more than 1,500 children a year die from abuse; 90% of these are children under the age of 3.  The number of children with disabilities  who die from abuse is undetermined.  Year after year the tragedy continues.

So those of us across the spectrum of health providers must be vigilant observers…and listeners.  Children of differing abilities based on their age and on their abilities have different ways of communicating with us and we need to be paying attention to any indicators that a child is at risk or is being treated abusively. We all need to remember that what is obvious, the glowing brilliant tower above the water is not our only concern.  Children, especially those who cannot always speak for themselves, who go unnoticed beneath the surface are the most vulnerable.  We all need to be committed to assuring their care, safety and well-being.  We are all called to be look-outs to save the lives entrusted to us.

Resources:

www.nlm.nih.gov/medlineplus/news/fullstory_121601.html

www.disabled-world.com/disability/…/childabusedisabilities.php

Child Abuse and Children with Disabilities

childabuse.tc.columbia.edu

Violence against Disabled Children

www.unicef.org/…/UNICEF_Violence_Against_Disabled_Children_.

7. Sexual abuse of children with disabilities

http://www.coe.int/t/dg3/children/1in5/Source/…/Brown.pdf

Conversations of the Stars

This past weekend in New York both Passover and Easter were celebrated.  Passover being a commemoration of the passing over of the angel of death thereby sparing the lives of Jewish firstborn children.  Easter is the celebration of Jesus rising from the dead after being crucified.  Whether you participate in these religious rituals and believe in the miracles of lives saved/a life rekindled, or if you just enjoy the family and friendship of a Passover dinner or revel in the fun of an Easter egg hunt, or have no personal connection with either of these religions or these holidays, it is evident that they are both about life and death being inextricably bound together.

Those of us who work in public health frame much of what we do in terms of health problems that increase morbidity and mortality rates, interventions that yield outcomes of lowered rates of mortality and morbidity, measuring the outcomes in lives saved/lives lost, quality of life, costs/benefits, basing evaluations of determinants and distributions of health.  There are experimental studies, quasi-experimental studies, ecologic studies, observational studies, cross-sectional studies and case/control studies.  This all sounds very boring and very academic, but actually it is all about life and death.  A flip through the most recent issue of the American Journal of Public Health reveals:  Genetic Physiological, and Lifestyle Predictors of Mortality in the General Population; Effect of Intensity and Type of Physical Activity on Mortality: the Whitehall II Cohort Study; US Cultural Involvement and Its Associations With Suicidal Behavior Among Youths in The Dominican Republic; Worrying About Terrorism and Other Acute Environmental Health Hazard Events; The Role of Health Systems and Policies in Promoting Safe Delivery in Low- and Middle-Income Countries..  To those of you outside the public health world and even to some of us in the public health world, these studies may seem esoteric and abstract, but they are really about lives lost, lives that can be saved, lives that can be rekindled.

I participate in a few Linked In forums:  Global Health Public Health, Water Sustainability, my New York Medical College group.  The conversations in these groups also are about life and death and pretty much everything in between.  I have met some amazing people in these conversations as we talk about research and programs and we share our own personal thoughts, feelings and ideas.  I have met Kato and David and Mebra and Cornelia and Gordon and Mary and Keith and so many others who experience life and death on a very personal level.  There has been a long-running Global Health discussion on why maternal mortality remains so high in Sub-Saharan Africa which was started by the question raised by Jane on March 4.  A couple of weeks ago I consolidated responses into several broad categories: resources, education for girls and women, poverty, tradition and culture, funding, empowerment and the topic that keeps surfacing, political will.  I’ll add this to the end of this post.  There have been comments that cite statistics and data, programs, outcomes, but mostly there have been the comments about hurt and frustration and challenges and through the conversations incredible commitment to save lives and increase health and well-being.  And what I think often is not communicated in the research and the peer reviewed articles, is PASSION.

There has been another conversation about why public health is so often unrecognized as the powerful agent of change and life-saving interventions.  Think about the media, films, songs, TV shows.  Where are the public health professionals?  There are sexy doctors, there are romantic lawyers, there is Nurse Jackie, definitely detectives and police officers and crime lab specialists.  Public Health?

The passion of public health, the commitment to saving lives, the miracles that are perhaps sometimes lost in the data need to shine through like stars.  I invite all of my colleagues in public health to tell the stories of life and death and anyone who will listen, who must listen, to hear.  When I think about the challenges of saving lives, especially in maternal health and birthing, I think about the last verse of W.H. Auden’s poem September 1, 1939:

Defenseless under the night

Our world in stupor lies;

Yet dotted everywhere,

Ironic points of light

Flash out wherever the Just

Exchange their messages:

May I composed like them

Of Eros and of dust,

Beleaguered by the same

Negation and despair

Show and affirming flame.

To my dear colleagues around the world who continue to teach me about your work and commitment, I thank you for being the stars continuing to shine and show the way to life.

Why is maternal death still high in Sub Sahara Africa despite all the effort being made globally?  Posted by Jane on March 4, 2012

Literature referenced:

Declaration of AlmaAta

http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

Annie Feighery  http://participatoryapi.posterous.com/three-years-of-the-bright-conference-on-brandi

Hogan, M.C., Foreman, K. J., Naghavi, M., Ahn, S.Y., Wang, W., Makela, S.M., Lopez, A.D., Lozano, R., Murray, C. J. L.  (2010).  Maternal mortality for 181 countries, 1980-2008:  a systematic analysis of progress towards Millennium Development Goal 5. www.thelancet.com/journals/lancet/article/PIIS0140

Unger, J.P., Ven Dessel, P., Sen, K., & De Paepe, P. (2009).  International health policy and stagnating maternal mortality: is there a causal link? Reproductive Health Matters. 17(33), 91-104.

Karel Amaranth, MPH, MA.  MPH Thesis: Safe Motherhood By Design:  A Public Health Program Planning and Evaluation Project:  Empowering Women to Prevent Maternal Mortality 
  
 
Contact:   roguewaverose@gmail.com

www.positivedeviance.org

www.lifeforafricanmothers.org

Cornelia Osim Ndifon:  Determinants of Maternal Mortality Amongst Unbooked Patients in Calabar Teaching Hospital Nigeria:  A Four Year Study.  Contact:  lovecornel2002@yahoo.com

Riders for Health www.riders.org

Holistic care, Inter-relationship of resources, workforce, education, poverty reduction, nutrition

Trends in responses:

EMPOWERMENT:  Social injustice/human rights issue/gender equity

Women’s empowerment as a determinant of higher education, reduction of poverty, social status and ability to make informed health choices including spacing of pregnancies, contraception, healthy birthing practices, prevention of HIV

Women’s health as holistic including empowerment:  Inter-relationship of MDGs: maternal/child health, water, nutrition, sanitation, transport, education, agriculture

Community empowerment: Programs that Ask women what they want and need

TRADITION/RELIGION/CULTURE

Early marriage and child bearing

Religions that do not allow contraception

Women believe it is their fate or Allah’s/God’s will for them to suffer and die.

Cultural implications of having many children, i.e., virility of the father

Male dominated society (suggestions to engage men, rather than condemn them)

Female circumcision, violence against women

Very high fertility rates and multiple births (related to cultural and socio economic pressures)

EDUCATION OF WOMEN AND GIRLS

Specific to health/child bearing/reproductive health

General education of women and girls; reducing illiteracy

Developing women’s leadership

POVERTY

Association of poverty with low social status, poor nutrition*, no or limited access to healthcare,

Impact particularly on pregnant teenaged girls and unmarried women

Impact on low birth weight and infant mortality

*Nutrition:  Importance of reducing anemia, building strong bones and resistance to infections.

HEALTH RESOURCES

Supplies:

clean birthing kits, misoprostol, oxitocin, equipment in hospitals (often inadequate)

Healthcare facilities/interventions:

Inadequately staffed and equipped.

Not accessible by rural women

Services like EmOC not available to all women

Distance from healthcare facilities/transportation

Effectiveness of focus on home deliveries to reduce MMR/home birthing as a positive choice with clean supplies and birth attendant

Skilled attendance at births:

Traditional birth attendants

Negative: interfere with safe birthing

Positive:  need to be recognized, trained and engaged since many women continue to use them

Midwives

Community Health Workers: part of a decentralized health delivery system; performance based financing

Physicians (very little mention of physicians)

Limited resources for training  any of the above health providers.

Lack of healthcare infrastructure to deliver services to women

GOVERNMENT/POLITICAL WILL

Leadership not committed to healthcare infrastructure

Government policies that do not favor women

Inefficiencies in government, corrupt use of funding and cumbersome bureaucracies

Governmental should encourage economic development to support healthcare delivery infrastructure that supports community in a decentralized health system; grass roots empowerment rather than out of touch corrupt government programs

Improvement in MMR even in low income countries if there is political will is focused on health

FUNDING (Government and Private Sector)

Funding channeled to women’s health, education and empowerment

Informed donor base to ally funding for poverty reduction with funding to reduce maternal mortality

Performance based financing

SCIENCE

Evidence based practices:  what evidence is used to support programs and interventions?

Quality assurance in programs.

Research and successful interventions:  sharing the knowledge and replicating successes

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