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California-Trained Doctor Helps Keep Liberian Hospital Open During Ebola Crisis

While many run from the Ebola outbreak in West Africa, some brave souls are running toward the region to help. Dr. James Appel is one of those. Trained in the Inland Empire at the Loma Linda University School of Medicine, he's been working for Adventist Health International at hospitals in Chad for the last decade. Last week, Dr. Appel flew to Liberia to keep the doors open at Cooper Adventist, a small hospital in the capitol, Monrovia.

PBS NewsHour

New drug may ‘change the foundation’ for treating heart failure

Novartis

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HARI SREENIVASAN: As we reported yesterday, an experimental heart drug developed by the Swiss pharmaceutical company, Novartis, shows promising results.

The new drug currently referred to by its codename “L C Z 696″ may change the course of treatment and prolong the lives of patients suffering from heart failure.

The results of the study on the new drug are being presented this weekend in Spain at an international cardiology conference and were also published yesterday by The New England Journal of Medicine.

For some insight, we’re joined via Skype from Windham, New Hampshire by Clyde Yancy, he’s a professor of medicine and chief of cardiology at Northwestern University.

So, Professor Yancy, there are millions of people around the world, who suffer from heart disease and heart failure, what’s so different about this drug and why does it work better than what’s available today?

CLYDE YANCY: Well Hari, thanks for your interest. Those millions of people you talked about should be elated because there is a new therapy now.

It’s not just an additional therapy, but it is a significant improvement over what we already had. This really is better and brings a lot of hope to a lot of people.

HARI SREENIVASAN: And without getting too far into the details of the science, what’s it doing to the heart to make it more efficient or less prone to fail?

CLYDE YANCY: So that’s a great question. It takes what we originally were doing, which was to use drugs to help make the heart smaller and stronger, but then takes it a step further.

So not only does it help to make the heart smaller and stronger, but it reverses or minimizes some of the scar that happens over time.

By combining these two effects together, it really has a profound influence, a new benefit on living longer and feeling better.

HARI SREENIVASAN: Now would this replace the type of treatments we have today? I mean we’re familiar with a category of drugs called ace inhibitors and beta blockers.

CLYDE YANCY: So Hari that’s why there’s so much excitement. Rarely are we able to change the foundation of how we do things.

This changes the foundation, which means it raises the bar for all patients. We do think that many patients will  have their ace inhibitors replaced by this new ”L C Z” drug once it’s developed further.

But it’s also important to realize that the background therapy still includes drugs that we know make a big difference like beta-blockers, like MRA’s, so lots of reason for enthusiasm here.

HARI SREENIVASAN: So while this one company has kind of a lead here, how long until this category of drugs gets on the markets and on store shelves so to speak, where doctors can write a prescription for them in the U.S.?

CLYDE YANCY: I really think we can go beyond which company has what proprietary input here and realize that this really is a breakthrough for patients and so it means we have to change the dynamic here.

We have to look to the F.D.A., work with the F.D.A. and say how can we bring this development to the table, sooner and better than we’ve ever done before.

I’m excited about the possibility of helping to galvanize interest and get this drug to patients as soon as possible.

HARI SREENIVASAN: You know some people are concerned that perhaps it’s too quick.

I’m mean I don’t know what the medical ethics of it is when you have this kind of medical efficacy and want to get this drug out there and help more people, but are there side effects that we don’t know about, particular populations that haven’t been studied enough?

CLYDE YANCY: You know what Hari, the answer is yes and yes, but it doesn’t drop our enthusiasm or quell our interests.

Here’s the story, we need to move forward with something for heart failure, that’s pretty clear.

Yes, there are patients that we wish we knew more about, like African American patients, like more U.S.-based patients, like more patients with more advanced heart failure, but nevertheless, there are ways used in contemporary research methodologies that we can get those questions answered, while still bringing this to the table.

This really isn’t about a company. This is about a brand new approach, a brand new way to take care of people that have a pretty compelling disease.

If the disease wasn’t so compelling, sure we could slow down, take some more time, get some more data.

But we’ve got a disease, where people are coming up short despite getting everything that we have available now.

We really should think about bringing this forward as soon as we can.

HARI SREENIVASAN: Alright, Clyde Yancy of Northwest University, thanks so much for your time.

CLYDE YANCY: Thank you for your interest, I appreciate it.

The post New drug may ‘change the foundation’ for treating heart failure appeared first on PBS NewsHour.

How did the West Africa Ebola epidemic get out of control so fast?

Liberia Battles Spreading Ebola Epidemic

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HARI SREENIVASAN: The spread of the most recent strain of the Ebola virus across parts of West Africa has highlighted not just the lethality of the disease but also the strains on the existing medical infrastructures there. For further insight, yesterday I spoke with Stephen Morse, professor of epidemiology at the Mailman School of Public Health at Columbia University and Estrella Lasry, tropical medical advisor at Doctors Without Borders.

HARI SREENIVASAN: First, why is this strain so much more lethal compared to others? I mean we’re talking 3,000 people infected, 1,500 dead.

STEPHEN MORSE: I don’t think it’s more lethal than other strains of Ebola Zaire. This is a highly lethal virus. I think the problem is that there are a large number of people getting infected and perhaps some of them are not getting care at the appropriate times. But I don’t think biologically it’s behaving much differently than the ones we already know about.

HARI SREENIVASAN: Is there a different social component on why this is spreading faster?

STEPHEN MORSE: I think that initially with the outbreak in Guinea, it was allowed to get out of control and there were just so many patients by then, it began to spread across the borders. And, so by time, the organizations like Médecins Sans Frontières, Doctors Without Borders, were able to start on it in the Spring. There were already so many cases of this, it was an uphill battle.

HARI SREENIVASAN: Why has the international kind of effort to try to combat this been so much slower than it seems that we’ve heard about in the past? Your organization is one of the last ones there and you have a number of people there, but you don’t see the same kind of push from lots of international aid agencies going in.

ESTRELLA LASRY: Well, usually the outbreaks aren’t as big as this one. So, we expected it to – we started working on the outbreak in March and we expected it to finish in two, three months, which is what we would usually see in an Ebola outbreak and in the Ebola outbreaks that we’ve been responding to in the past. Part of the problem with this outbreak is that it spread very quickly in an urban area, which meant that it was much more difficult to control in terms of the contact tracing and it was much more difficult to control in terms of how quickly it spread. So, it’s lasted much more than the previous outbreaks and it’s affected a lot more people and that’s why there is an absolute need for more organizations to get involved in the response.

HARI SREENIVASAN: You know, this is also highlighting kind of a disparity in kind of poor existing medical infrastructure. Some of these countries, entire countries, have less doctors than, say, a single hospital in a major Western city. And then there’s also a disparity between countries who’ve dealt with this virus before versus countries who have not.

STEPHEN MORSE: Yes, absolutely, and these countries, I think, are particularly stressed because they’ve had civil strife, they have trouble between the government and the local people – some distrust of government. So, you know, that is overlay over an already difficult and strained medical infrastructure. But even Nigeria, which is the very big country by comparison, has only 17,000 doctors.

HARI SREENIVASAN: How significant is the fear factor, the misinformation in spreading the disease, or chasing away caregivers?

ESTRELLA LASRY: It’s huge. It’s a big part of why the outbreak has been spreading so much. So, if the fear is causing people not to go to health facilities, to hide the disease, to hide people who have died in the villages. We’re not being granted access to some of the villages where we think there might be cases, so definitely it’s been playing a pivotal role in why the disease has been spreading in the way that it is spreading.

HARI SREENIVASAN: What’s the distrust? Why not let a doctor come into a village? What do you hear?

ESTRELLA LASRY: Well, first of all it’s very difficult, there’s been a lot of people who have died and a lot of people are taken into isolation wards. We’re dressed in the full personal protective equipment, the astronaut suits that you’ve been seeing on TV, and of course it adds to the fear, the fact that we’re bringing people into these wards. So, one of the things we try to do is ensure that family members do have access to see their relatives who are inside the ward, creating some kind of terraces where there’s a barrier, a physical barrier, between the family member and the patient. But it allows them to see their family member, it allows them to see that they are inside the ward, but they are being taken care of and we’re not hiding them.

HARI SREENIVASAN: You know, I even saw reports that kind of reverse causality, they say, you know everywhere these doctors go, more people are dying, so let’s keep the doctors out.

ESTRELLA LASRY: But it’s understandable that that kind of fear would be created in a population that does not know the disease and that is not used to this kind of response to a disease like that.

STEPHEN MORSE: In addition to perhaps a mistrust of authority and of course people coming from foreign countries to help, but since it has such a high mortality rate, normally the case fatality rate is fairly high and many people feel that there’s no point in going to the hospital anyway. And in some cases if infection control isn’t effective, in some hospitals other patients can get affected. There’s a historical basis for that. We can do much better now and Médecins Sans Frontières has demonstrated the improvements that are possible even with general care. But I think it needs educating the public about that.

HARI SREENIVASAN: So, really by the time they get to the hospital sometimes they’ve already infected thousands of others.

ESTRELLA LASRY: Yes, and the sooner someone who has been in contact with a patient, with a known case, actually says that they have been in contact, or the sooner that person is identified, the sooner they can be monitored. So, what’s happening is that for every case, for every confirmed patient, all of the contact, all of the physical contacts that they’ve had in the past 21 days are monitored on a daily basis. So, you can imagine how huge the response to that needs to be, especially with the amount of cases that we’re seeing. But not everybody is saying all of the contacts that they’ve had, or not everybody is willing to be followed for 21 days on a daily basis. So it’s also one of the challenges.

HARI SREENIVASAN: So, looking around the corner a little bit, we’ve had some promising results with ZMap and the tests that have been – how far away are we from anything close to what we could say is a vaccine that could be manufactured at scale that could actually reach this region?

STEPHEN MORSE: Scale is going to be a difficult problem, even with ZMap, they’re working very hard to try to scale it up just to experimental doses and it’s going to take a while. Some of the other drugs in the pipeline will take longer, because they need to be tested. As you know there’s a vaccine candidate going into early trials right now for safety testing essentially. But then the question is what’s the market for that vaccine. People who are going as healthcare workers, or lab technicians, or others who would be dealing directly with patients would be clearly able and willing to get the vaccine. But this is sporadic, we don’t know where the next Ebola outbreak is going to occur. So, you’re never quite sure whom to vaccinate until it actually happens.

HARI SREENIVASAN: Given that there are so few doctors and so many cases, what do you do to keep your own staff safe? I mean they’re working under incredible stress, under very long, difficult conditions, and people make mistakes when they’re on 18 hours a day, etc., etc., and these mistakes could cost them their lives.

ESTRELLA LASRY: We do several things. The first thing is to train people before they go to an outbreak. Once they’re in the outbreak, we make sure that they really understand the infection control, and if at any point they feel unsafe they can leave. But also once you go into the ward, we have a buddy system. So, you will never go into the ward alone. You dress with someone to make sure that there’s no skin, nothing is exposed. And then you go into the ward with at least one other person, so that in case you’re about to make a mistake, the other person can actually warn you. So, we try to keep everyone within a very, very strict set of rules, because there’s no place for mistakes.

HARI SREENIVASAN: Alright, Estrella Lasry, Stephen Morse, thanks so much.

ESTRELLA LASRY: Thank you.

STEPHEN MORSE: Thank you.

The post How did the West Africa Ebola epidemic get out of control so fast? appeared first on PBS NewsHour.

Gay rights, sex workers and HIV prevention: Uganda’s activists answer your questions

Editor
         of the Ugandan publication Rolling Stone holds a November 2010 issue of his newspaper, which published the names and photos
         of 14 men it identified as gay. Photo by Marc Hofer/AFP/Getty Images

Editor of the Ugandan publication Rolling Stone holds a November 2010 issue of his newspaper, which published the names and photos of 14 men it identified as gay. Public health experts say discrimination directed toward the LGBT community hinder many individuals from seeking treatment for HIV/AIDS in Uganda. Photo by Marc Hofer/AFP/Getty Images

As HIV infections and AIDS-related deaths around the world fall, rates in Uganda have been on the rise in recent years. Part of the problem, according to many of the world’s top public health experts, is that the populations most at risk for HIV infection — including gay men and sex workers — face laws that do little but increase stigma, drive these groups underground and make them reluctant to seek life-saving diagnosis and treatment. Among the most problematic laws, they say, are the the U.S. “anti-prostitution pledge” and Uganda’s new Anti-Homosexuality Act (which was ruled invalid by a Ugandan court Aug. 1 due to a technicality but is likely to resurface).

The PBS NewsHour explored the issue in July:

After the NewsHour segment aired, we put the call out for your questions for four activists and human rights workers who deal specifically with at-risk populations in Uganda.

Daisy Nakato is a Ugandan sex worker and founder of WONETHA, an organization that seeks to educate and empower sex workers in Uganda, and Megan Schmidt-Sane is a former WONETHA staff member who now works for the Sexual Health and Rights team at American Jewish World Service.

Asia Russell is the director of international policy at Health GAP, a nonprofit dedicated to improving access to care for people living with HIV/AIDS.

Isaac Mugisha from Spectrum Uganda — an LGBT advocacy group based in Kampala — also planned to answer your questions. Unfortunately, he is currently recovering in the hospital following a brutal attack in which he was targeted for his associations with the LGBT community. If he is able to provide an update after his recovery, we will add his comments here.

The answers below are the opinions of the activists and do not necessarily reflect the views of PBS NewsHour.

NewsHour Viewer 1: Can you address how religious institutions in the country are either assisting to mitigate HIV contraction or driving the rise in HIV contraction through rhetoric or policy? How do connections to U.S. evangelical communities contribute to this either in helping or hurting the situation?

Faith-based groups that take on a moralistic perspective and inspire fear and hatred are fueling the HIV/AIDS epidemic, rather than helping to mitigate it.
Megan Schmidt-Sane: Religious institutions in both Uganda and the U.S. are not a monolithic entity — faith-based organizations and institutions that are respectful of the local culture and understanding of the realities of the HIV epidemic have had great impact. However, some international and local religious groups have also had a negative impact — from pushing for repressive and stigmatizing policies like the Anti-Pornography Act and the Anti-Homosexuality Act, to denying the need to address HIV among key populations from a rights-based perspective (meaning, a focus on the right to work and live free of discrimination, and violence). Faith-based groups that take on a moralistic perspective and inspire fear and hatred are fueling the HIV/AIDS epidemic, rather than helping to mitigate it.

Most recently, a lot of attention has been given to the Anti-Homosexuality Act. A recent film, called “God Loves Uganda,” details the connection between the U.S. evangelical community and Ugandan religious institutions, policy and practice. It especially talks about the impact of U.S. pastor Scott Lively’s proselytizing in Uganda and his address to the Ugandan Parliament in 2008. His intolerant speeches have been tied to the most recent wave of anti-homosexuality sentiment and to the subsequent passage of the Anti-Homosexuality Act.

There is one innovative way that we have been able to hold U.S.-based individuals accountable for fomenting hate in other countries. On March 14, 2012, the Center for Constitutional Rights (CCR) filed a federal lawsuit on behalf of Sexual Minorities Uganda (SMUG), a nonprofit umbrella organization for LGBT advocacy groups in Uganda, against Scott Lively. The case was filed with the United States District Court in Springfield, Mass., and alleges that Lively’s involvement in anti-gay efforts in Uganda, including his active participation in the conspiracy to strip away fundamental rights from LGBT persons, constitutes persecution.

Asia Russell: Some religious groups are providing life-saving health service delivery in Uganda — but others actually increase harm by promoting stigma and bigotry, providing inaccurate and harmful information about HIV prevention and contributing to lack of information among Ugandans about how to prevent HIV transmission. “Abstinence until marriage” HIV prevention programs, for example, do not work and can actually increase the risk of infection for the reasons stated above.

Comprehensive and accurate knowledge about HIV and how it is transmitted has increased from 35 percent to only 38 percent among men and from 30 percent to only 37 percent among women between 2006 and 2012. We need religious institutions to deliver comprehensive, accurate, evidence-based and human-rights-supporting HIV services, or else Uganda’s HIV response will continue to be woefully off track. In 2012, an analysis by Health GAP showed that Uganda was enrolling fewer people in treatment than other countries in the region, and the stakes could not be higher — new evidence shows that earlier access to treatment for everyone with HIV is critical to creating an AIDS-free generation.

But more than any other factor, the Anti-Homosexuality Act — now nullified in Constitutional Court — was about scapegoating an unpopular segment of the population for political purposes — and to increase President Museveni’s chance of reelection.

NewsHour Viewer 2: To protect sexual health, what do you find to be the most successful interventions for sex workers, and for those who are LGBT?

Daisy Nakato: As a sex work organization, WONETHA can answer the first part of this question. Those of us who have worked on sex worker rights issues know from experience that the most successful interventions need to be community-based (led by sex workers) and rights-based (an approach that recognizes our right to engage in sex work and to live free from discrimination and violence) as well as structural and not solely biomedical (such as medication or HIV testing). Sex workers need to have a meaningful voice in programming, at all stages of planning and implementation; sex workers need to be recognized as experts in their own lives.

In addition, sex workers need to be empowered to access health services that are free from stigma and discrimination. We have long known that structural interventions such as the decriminalization of sex work would go the furthest in improving health for sex workers.

Recent research using statistical modeling in The Lancet Special Issue on HIV and Sex Work confirms what activists and sex workers have long known — that the “decriminalization of sex work would have the greatest effect on the course of HIV epidemics across all settings reviewed by the paper, averting 33—46 percent of HIV infections in the next decade.”

Russell: First, sex workers must be engaged as equals in designing and implementing programs. When sex workers themselves are trained and supported to provide services — such as educating other sex workers and clients in safe sex and providing HIV testing and treatment — behaviors change and communities become more resilient to HIV and other sexually transmitted infections. LGBT communities also need supportive prevention and treatment services, where they can be free from the threat of retaliation or persecution. Model programs typically combine training for health workers in non-discrimination, along with supportive clinical services that include peer-based outreach, prevention, care and patient follow-up.

Unfortunately, shrinking budgets for treatment and prevention programming, including PEPFAR, a U.S. initiative that is the biggest funder of the HIV response in Uganda, mean efforts to expand human rights based interventions are not being scaled up fast enough and are at risk of budget cuts.

NewsHour Viewer 3: Is there any outside pressure, a leader of another country, a prominent activist figure, who could change Ugandan President Yoweri Museveni’s idea that sexual identity is a “choice”? Who could influence him to reject such harsh discriminatory laws?

Nakato: To be quite honest, what is needed is an amplification of indigenous LGBT voices from Uganda to speak out against these ideas. Many activists from the community have long been engaged in changing Museveni’s mind, and this tactic was working. When U.S. or European leaders get involved in a public way, it plays into the anti-LGBT rhetoric that “homosexuality” is a Western import, and this may actually do more harm than good. What is needed is more private, sustained engagement to put pressure on Museveni to change his mind.

Russell: All leaders have a role to play in holding policymakers accountable for harmful laws such as the Anti-Homosexuality Act. The actions of one leader on his or her own are never enough to result in societal change. But ultimately, national and global pressure led by civil society will become too intense, and we will see a day when all discriminatory laws are repealed and leaders are accountable to all their people—including minorities. For example, the decisive victory in nullifying the Anti-Homosexuality Act [in court] was only possible because of successful, smart advocacy.

NewsHour Viewer 4: I’m telling you, gay people in Uganda can register for services like the rest. No one is denied services in Uganda because they are gay, no service cuts! We’re tired of your lies! Health care is for all. [Response?]

Russell: Unfortunately, you are mistaken. Discrimination in the health sector is alive and well for LGBT Ugandans. The police raid on the Makerere University Walter Reed Medical Research Centre showed that beyond a shadow of a doubt. Many clinics providing outreach services for LGBT groups also had to close because they were afraid to be accused of “promoting” homosexuality.” In a High Court ruling on whether the Ugandan government was in violation of the constitution when the Minister of Ethics and Integrity shut down a meeting of human rights defenders in 2012, the court sided with the government in equating talking about health rights of gay men with the criminalized act of same sex activity between adults.

Clearly, the real question is how we overcome both the fear of discrimination that keeps gay people from seeking services and the actual discrimination at the level of service delivery. Decriminalization is a vital step.

NewsHour Viewer 5: What proof do you have that people aren’t getting the services they need? Do you have numbers that show a drop in treatment for gay people?

Russell: Health service delivery for LGBT communities was only getting started in 2013, when the bill was signed — people were just beginning to feel comfortable seeking services. Even so, the U.S. government-funded PEPFAR program in Uganda reported an almost immediate decline in use of LGBT clinics following passage of the bill into law.

NewsHour Viewer 6: How have things changed for the gay community since the Anti-Homosexuality Act was passed? Given that homosexuality was already illegal, did this new law really have that big of an impact?

Russell: Unfortunately, it has had a huge impact — from calls in communities for mob violence to landlords evicting gay tenants to outings of gay Ugandans in the news tabloids. A recent report released by Sexual Minorities Uganda, or SMUG, showed a dramatic increase in reports of abuse, violence and extortion in the five months after parliament passed the bill.

Importantly, the existing anti-sodomy law had not been enforced in recent memory — until parliament stepped up its homophobic, human-rights-violating stance. In addition, the Anti-Homosexuality Act included sweeping new provisions and harsh new penalties. For example, the bill criminalized the provision of services to members of the LGBT community, whereas the previous law had only criminalized same sex activity between consenting adults.

NewsHour Viewer 7: What role does stigma play in preventing people from receiving services for the LGBT community and for sex workers?

Nakato: Stigma has caused the death of WONETHA members too afraid to seek treatment for fear of being attacked or rejected by the very health care workers supposed to assist them.

Stigma and discrimination are broadly recognized factors that contribute to the spread of HIV/AIDS globally, and both stigma and discrimination very much prevent sex workers from accessing legal, social, economic and health services. This kind of exclusion is particularly detrimental and visible in the HIV/AIDS epidemic — where 11.8 percent of female sex workers globally (The Lancet Special Issue on HIV and Sex Work, 2014), and 33 percent of female sex workers in Kampala, Uganda (Crane Survey Report, 2010), are living with HIV.

Whorephobia, homophobia, transphobia and other prejudices may be demonstrated by health care workers as well as other service providers. In Uganda, health care workers may ask invasive questions about an individual’s occupation, sexual history and other questions that are unnecessary and inappropriate. Indeed, many of our sex workers report health care workers requiring an individual to seek treatment with their partner. Sex workers may feel that a health care facility or other service provider is not friendly or open, and they may refuse to seek services because of this.

Russell: Stigma is a completely unnecessary but substantial barrier to accessing health services for sex workers, LGBT individuals, and people with HIV who are not part of those vulnerable groups. In Uganda, and in many other countries, criminalization of populations achieves nothing except to drive people further from essential services because of fear of widespread intolerance.

Transforming attitudes and beliefs toward the LGBT community and sex workers as quickly as possible, and demanding policy makers uphold their rights and prosecute violations of those rights, are essential steps in ending the HIV epidemic in Uganda and around the world.

NewsHour Viewer 8: What impact do the tabloids and media outlets have in fueling discrimination at the moment?

Nakato: Tabloids and media outlets portray sex workers in a negative light, accusing us of fueling the HIV epidemic and of being vectors of disease and moral decay. At worst, the media publishes our faces without our consent, which leads to outright violence and stigma from the rest of the community. This kind of “outing” is incredibly harmful and has damaged many lives — both emotionally and physically. Indeed, David Kato, an activist from Sexual Minorities Uganda, lost his life in 2011 in the wake of being published in the Rolling Stone. (Editor’s note: Rolling Stone was a weekly tabloid published in Kampala, Uganda, with no affiliation with the American magazine of the same name.)

In addition, when police raid a “red light area” in Uganda, they often call the media, like Bukedde News, to accompany them. This practice is harmful and unjust. Under the Ugandan Constitution, everyone is entitled to a free and fair trial. Putting people on trial and judging them in the public eye, before this happens, is unfair and unconstitutional. This practice needs to be stopped.

Russell: Hateful media reporting in Uganda foments violence, ignorance and intolerance among ordinary Ugandans, as well as politicians, religious and cultural leaders, and all sectors of society. In general, media outlets — with only a few exceptions — use homophobia to sell papers, and use sensationalist coverage to intensify hatred. Educating the media and demanding accurate and sensitive coverage, along with prosecuting media outlets that promote hate speech and violate Ugandans’ constitutional right to privacy, are essential steps in transforming society.

NewsHour Viewer 9: The government of Uganda says it’s important to offer services to “at-risk groups” in its wider effort to push down HIV rates. So what services is it offering to LGBT people and sex workers after this law was passed?

Nakato: Right now, the government of Uganda only offers services to “at-risk groups” through the Most-at-Risk Populations Initiative (MARPI) Clinic at Mulago Hospital. This is just one small clinic serving the entire country — this model should be scaled up to other areas of Kampala and up-country as well.

NewsHour Viewer 10: Is it possible for these groups to work directly with the government (including police) toward the goal of reducing HIV? If so, what strategies have worked?

Nakato: Yes, we have worked closely with police in terms of sensitizing them on how to work with sex work communities. In most cases where we have built relationships with police and local leaders, we have been able to successfully engage them on a wide range of issues, and we have even halted much of the harassment that is going on. However, this relationship building requires time, patience, and resources — we need to work with police and local leaders in all areas of the country, but also at the higher levels. We have been doing so, slowly, but with limited time and resources.

Schmidt-Sane: Building off of what Daisy has said about WONETHA’s work in Uganda, most sex work organizations around the world are able to effectively engage police and local leaders; this has often led to a reduction in harassment, and increased cooperation between sex workers and law enforcement in terms of addressing other important issues and crimes.

NewsHour Viewer 11: Can’t sex workers receive treatment like anyone else? What’s stopping them from going to clinics and receiving the care they need?

Nakato: In Uganda, the main barriers to receiving treatment are structural and financial. Even if sex workers wish to receive treatment for any number of things, the issue is that the criminalization of the industry makes it nearly impossible to do so. Sex workers are rightfully afraid of arrest or being laughed at or talked about when they go to a health center. In addition, because of constant police harassment and arrest, sex workers find themselves in a cycle of imprisonment, poverty and housing insecurity and increased risk of contracting HIV and then sustaining treatment. Taking ARVs (antiretroviral drugs) is not as simple as one might expect — it requires proper nutrition, abstinence from alcohol and drugs, overall well-being and most importantly, a consistent schedule in terms of taking medication at the same time each day.

Much of the HIV/AIDS funding in Uganda comes from the U.S. government, and with that comes restrictions on giving funds to sex worker rights organizations — the very organizations that are most likely to reach sex workers. Therefore, those who are most in need of treatment are not often able to access it. At WONETHA, we have peer educators in the field who are constantly in touch with the community and who are aware of those who need treatment. Our model is evidence-based and it works. However, we are unable to access U.S. HIV funding because of the anti-prostitution loyalty oath.

In 2003, the U.S. Congress passed a piece of legislation titled the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act. More commonly referred to as the Global AIDS Act, it established the President’s Emergency Plan for AIDS Relief (PEPFAR) as well as the State Department’s Office of the Global AIDS Coordinator. Specifically, the act provided funds for assistance to foreign countries in order to combat HIV/AIDS, tuberculosis and malaria. Congressman Christopher Smith (R-NJ) included a limitation in the law that prohibited the use of federal funds to “promote, support, or advocate the legalization or practice of prostitution.” It required organizations that received HIV/AIDS funding to adopt a policy explicitly opposed to prostitution. Often referred to as the “anti-prostitution loyalty oath,” this amendment has been a contentious part of the Global AIDS Act. However, all evidence has shown that isolating sex workers is not effective public health policy. Organizations that work with sex workers have been successful in combating HIV/AIDS rates and have even taken direct measures to identify trafficking victims.

For a global perspective on this question, see this Global Network of Sex Work Projects briefing paper.

NewsHour Viewer 12: WONETHA advocates for the decriminalization of sex work. But would decriminalizing sex work have any impact on public health? Wouldn’t that encourage more people to engage in this kind of work, more people to purchase sex, and therefore increase the potential for the spread of disease?

Nakato: When sex work is considered a criminal act, sex workers have less power to negotiate openly with their clients about practicing safe sex. They become easy prey for police or others looking to extort money or gain sexual favors because sex workers are seen as having no rights under the law. The stigma of being classified as a criminal means that sex workers either face abuse and ridicule when accessing health and social services or stay away from them altogether. Decriminalizing sex work would make our work safer, would make it possible for us to seek justice when violence is committed against us and make it easier for us to access the health care services we need to protect our health and that of our clients. Removing the criminal laws around sex work is not about promoting the sex industry, it is about treating it like any other industry that provides basic rights and protections for workers.

It is also incorrect to place the blame on sex workers as “vectors of disease.” It is about making our work safe and free of violence, stigma and discrimination — decriminalization would go a long way toward reducing the high prevalence of HIV.

Russell: Sex workers in Uganda have some of the highest HIV rates in the world — 33 percent prevalence. They are in urgent need of prevention and treatment, delivered through programs that rely on their expertise and leadership. Evidence shows that decriminalization dramatically reduces the risk of HIV transmission for sex workers and their clients — a benefit that is passed on to their other sex partners, as well. Decriminalization has not been shown to result in greater prevalence of sex work. Instead, it is associated with sex workers having more power to demand safe sex, as well as protection on the job from physical and sexual violence, and extortion and blackmail by police — all extremely common occurrences in Uganda.

NewsHour Viewer 13: U.S. lawmakers say the anti-prostitution pledge is in place, in part, to help prevent trafficking. If it’s removed, wouldn’t that be a problem?

Schmidt-Sane: The U.S. anti-prostitution pledge restricts funding from going toward groups that work on sex worker issues from a rights-based perspective. Unfortunately, sex work is conflated with trafficking not only in this pledge definition, but by many other people working to end trafficking.

Despite the new international standard for trafficking, there is still an obfuscation of the distinction between trafficking and prostitution by abolitionist and religious members of the anti-trafficking movement. This conflation of sex work with trafficking can be questioned when we examine the wide range of reasons why a person can be trafficked. Globally, there is a disproportionate focus on trafficking into forced prostitution, with many conflating sex work and trafficking to the point where it is believed that all sex workers have been trafficked (see Ahmed & Seshu, 2012). In fact, numbers cited in the anti-trafficking movement are often estimates, or are simply fabricated. One report on trafficking in Cambodia points out that numbers on sex trafficking are inflated. Local anti-prostitution organizations claimed the existence of 80,000 to 100,000 persons trafficked for sexual labor in the country. The author reasons that is highly unlikely that Cambodia, with less than 0.2 percent of the world’s population, is also home to 11 to 14 percent of the world’s persons trafficked for sex (see Steinfatt, 2011).

NewsHour Viewer 14: Wouldn’t it be better to rehabilitate sex workers or help them find a different profession, rather than helping them simply stay safe while continuing sex work?

Nakato: Buying sewing machines for sex workers has never and will never work. The idea that working in a factory for 18 hours a day just to make a fraction of the pay is misguided. That said, WONETHA fully supports sex workers who willingly want to exit sex work, and we are committed to helping them find a way to do so. In addition, we encourage sex workers to save money in case of health or other emergencies, and to supplement their income with other kinds of businesses. We are not in the business of rehabilitation, and we do not make the issue of sex work a moral one. It is a labor-rights issue for us.

Schmidt-Sane: If a sex worker wants to engage in sex work, then that is their choice. For what other profession do we, as a society, so completely and patronizingly question one’s reasons for entering into that profession? Society needs to accept sex work as work.

Brothel raids and rescue tactics — the preferred method of extraction from sex work and subsequent “rehabilitation” — have resulted in documented human rights abuses such as rape, violence, unlawful detention and death while in custody of police or NGOs (see Cheryl Overs, 2009). Rehabilitation centers are simply a euphemism for jail — many of these places are overcrowded, dirty and uninhabitable and sex workers have died and suffered abuse while in custody.

NewsHour Viewer 15: Didn’t the U.S. Supreme Court strike down the anti-prostitution pledge last summer?

Schmidt-Sane: Yes, but this Supreme Court ruling only applied to U.S.-based groups. It does not apply to groups outside of the U.S., who apparently are not afforded First Amendment freedoms of speech that are guaranteed to those within the U.S.

NewsHour Viewer 16: If these “at-risk” groups, like sex workers, gay men and drug users choose to engage in high-risk behaviors, why should everyone else help them stay healthy?

Russell: Everyone has a human right to health, regardless of whether society accepts those people or not. But beyond this, the nature of public health means denying services to some of the population affects the health of us all — regardless of sexual identity or gender orientation.

NewsHour Viewer 17: Uganda was once known as a success story in fighting HIV, but that seems to have changed now. It’s one of the few places in sub-Saharan Africa where HIV rates are rising. What’s behind that trend and do laws against the most-at-risk groups play a role?

Russell: Uganda’s response to HIV has been woefully off track for years, and the country’s lack of investment in prevention and treatment for gay men and sex workers is one direct cause. Discriminatory laws and policies also fuel the epidemic. In addition, lack of action by the lawmakers and implementers has caused Uganda to lag behind in testing and connecting HIV-positive people to care and treatment. Advocacy and pressure from civil society groups means this is slowly changing. Hopefully Uganda will embrace a more sound approach.

Editor’s note: Activists’ answers have been edited lightly for style and clarity.

This series was produced with the support of the International Center for Journalists.

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Ebola outbreak started with funeral in Guinea, report finds

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HARI SREENIVASAN: The Ebola outbreak in West Africa has now spread to a fifth country amid forecasts that it will get far worse.  The latest case emerged despite efforts to stop the virus from crossing national borders.

The announcement came in Dakar, Senegal, a major tourist destination and transit hub that now has its first case of Ebola.

AWA MARIE COLL SECK, Minister of Health and Social Action, Senegal (through interpreter): It is a young student from Guinea.  He came for a consultation on Tuesday, August 26, at the hospital in an infectious state, without hemorrhaging, but hiding the information that he had contact in Guinea with people close to the victims of the disease.

HARI SREENIVASAN: Doctors confirmed the next day the man had Ebola.  He’s now in satisfactory condition.  Nearly 650 people in his home country of Guinea have been infected and two-thirds have died.  That’s the worst death rate of any country.

A new report in “Science” magazine traces the outbreak to a funeral on Guinea’s border with Sierra Leone in May.  At least 14 women were infected there.  Five local researchers who worked on the paper and collected samples from infected patients have since died of Ebola themselves.

In all, the World Health Organization reports 500 new cases this week, the most yet.

The director of the U.S. Centers for Disease Control says it could get much worse still.  He spoke yesterday in Sierra Leone.

DR. THOMAS FRIEDEN, Director, Centers for Disease Control and Prevention: If we don’t stop it here, we’re going to be dealing with it for years around the world.  But we can still stop it.

HARI SREENIVASAN: And a top official with Doctors Without Borders called today for a far greater international response.  Otherwise, he said, “I don’t see how we’re going to control the outbreak.”

For more on all this, I am joined by Stephen Gire.  He is a research scientist with the Broad Institute and Harvard University and a lead author on the study published yesterday in “Science.”

So, Stephen, tell me, how is it that you were able to go back and trace this spread of the most recent case of Ebola virus to one specific event?

STEPHEN GIRE, Harvard University: We used both epidemiological data, which is data that’s collected about people and who they’re in contact with when a disease happens, and then we paired this with genetic data that we collected from patient samples.

And we actually sequenced the full genome of the virus from 78 individual patients.  And so we used this data and the mutations that are there within that virus to actually build the sort of family tree that allows us to see, for one, how these viruses are related to each other, but then to see how we can trace them back to their origin.

HARI SREENIVASAN: So, when you got to the root of this particular tree, what is it about a funeral or what about African burial customs that made this the perfect ground for Ebola to spread?

STEPHEN GIRE: On May 25 in Sierra Leone on the border between Guinea and Sierra Leone, there was a funeral that took place of a traditional healer who had been treating Ebola patients in Guinea, and she had herself become sick and died of Ebola.

And it was at this funeral where a large number, a little over a dozen members, at the funeral were actually infected.  And we know this from epidemiological data.  But we also know that an attendant from that funeral was — actually came into the hospital at Kenema Government Hospital, which is where we worked, and was diagnosed.

And so we were then able to go out and find other people at that funeral and then start to build this phylogenetic tree or this family tree of what the virus actually looked like.

HARI SREENIVASAN: So, is it because people come in contact with a body that’s infected?

STEPHEN GIRE: That’s correct.

You know, the burial practices in a lot of African countries, the people or family — the friends or family that know the deceased person usually take part in preparing the body and washing it.  And just like funerals here in America and around the world, we often interact with the body once it’s dead.  There’s open-casket viewings and many people actually touch the body.

The same thing is true in Africa as well, and that can be a part of spreading this disease.

HARI SREENIVASAN: You know, one of the most serious costs of this paper was that five of your colleagues on the ground became sick and died in the work that they were doing.

STEPHEN GIRE: Yes, it’s really very tragic.

And I was on the ground in Sierra Leone, in Kenema, in early July.  And shortly after I returned and started processing the samples that we had collected for the study, we got word that a few of the members that had been a part of this project had become sick.

And, at that time, it was sort of numbing, and you didn’t quite accept the fact that they were sick, and you had hope that they would survive.  And so you kept pushing and kept doing your work.  And, you know, then word would come that somebody had died, and it would just sink in deep.

But, you know, just as hard as people have been working on the ground, we have also been trying to work very hard here to try to get this information out to the public, out to the scientific community, so that it can be used in this outbreak and other outbreaks.  So we have really tried to honor their memory by continuing to work really hard and push this information out so that it makes a difference.

HARI SREENIVASAN: All right, Stephen Gire, thanks so much for your time and your research.

STEPHEN GIRE: Thank you.

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