For the first time since the Nieman Foundation’s environmental journalism fellowship was established in 1994, journalists are invited to embark on a new specialized fellowship. In the fall, three journalists joined the Nieman class of 2007 as the foundation’s first Global Health Fellows. In each of the next two years, during this fellowship’s pilot phase, three journalists will be also selected as Global Health Fellows.

This fellowship is unique in that it combines the Nieman experience with a four-month fieldwork project in the developing world. After studying at Harvard for an academic year and meeting many major players in international public health, these fellows will take reporting trips to developing nations of their choice from June through September. This allows them to take a closer look at how health-oriented projects are carried out in the field and then return to the newsroom with stories ready to publish or broadcast.

Having been an international science journalist in the 2001 Nieman class, I now advise the Global Health Fellows in this Nieman effort. This opportunity arrives at a crucial time, when the intersecting complexities of global economics, international affairs, and health issues require a new level of expertise among journalists. Yet this is also a time when many newsrooms are reducing their staffs and resources and pointing towards localized coverage. In this environment, consumer health reporting is increasing, just when global health issues are urgently in need of news coverage. However, editors can scarcely afford to send a reporter on a three-month reporting trip to investigate, for example, the global business of counterfeit drugs, which kill people in faraway places, not in their hometown.

While more money and greater commitment exist in the global health arena today, a number of fundamental questions, such as whether funds are being spent effectively, remain unanswered — and are ripe for reporting. A specific intervention might work in some places but not well in others. Some aid organizations or local governments are more honest with their bookkeeping than others. Also, few donors and nongovernmental organizations are willing to engage beyond their prescribed agenda or collaborate with other aid organizations working in the same region.

Sorting out the many dimensions of the global health story and investigating the interconnectedness of health issues with global economic and political forces is part of the challenge of this fellowship — and of global health reporting in general. But an even greater challenge is to push this beat beyond conventional storytelling, which touches on compassion for the poor and sick in less fortunate parts of the world, by more effectively conveying how these far-away health crises are connected to our lives in the developed world.

In learning more about global health, as we’ve been doing this year at Harvard, we’ve come to discover many such connections — from the migration of African health providers to work in hospitals in the United States and the United Kingdom to the spread of infectious diseases from poor to wealthy nations.

By creating this fellowship — through the generous support of the Bill & Melinda Gates Foundation — the Nieman Foundation is participating in elevating the coverage of global health issues and in helping to define this vital, emerging beat. The three Nieman Fellows in Global Health Reporting, who are developing their fieldwork reporting projects, are Harro Albrecht, medical writer/reporter at Die Zeit, Hamburg, Germany; David Kohn, medical and science reporter at The (Baltimore) Sun, and Kondwani Munthali, a reporter and editor with the Malawi Broadcasting Corporation. Each describes, below, his plans for future reporting on global health issues.

Shared Lessons 

By Harro Albrecht

Are money, debt relief, and good intentions enough to solve global health problems and mitigate the burden of diseases in sub-Saharan Africa? Uganda is the ideal place to study the risks of foreign health aid implied in this question. In the 1990’s Uganda was the darling of health aid agencies, nongovernmental organizations, and private donors. With soaring HIV/AIDS rates, Uganda was one of the few African countries capable of tackling the problem, given that President Yoweri Museveni was one of only three African leaders who in 1986 acknowledged that HIV/AIDS was an urgent problem and recommended precautionary actions. His message seemed to be heard; citizens’ behavior changed. Consequently HIV/AIDS prevalence fell rapidly, from a reported 15 percent then to six percent now.

But hard-earned gains in Uganda’s fight against AIDS are eroding; HIV prevalence is on the rise again. Corruption has become a big issue in Uganda, and the Global Fund to fight AIDS, Tuberculosis and Malaria has withdrawn funds. Subsequently, the Commission of Inquiry revealed how funds meant for lifesaving AIDS drugs were spent by the contracted agency on personal phone calls, lavish "Christmas groceries," and the medical bills of former ministers. A question looms large: Did the huge amount of aid money harm the already weak health structures in Uganda? The focus on AIDS probably diverted money from other important medical concerns such as pneumonia, diarrhea in children, and maternal mortality. Especially in the neglected north of Uganda, citizens suffer from all sorts of diseases other than AIDS.

For a series of about six articles about global health issues, Uganda will be my starting point. These stories will offer an overview about the ongoing search for better solutions at a time when more money for health aid is available than ever before. The series will start at Harvard, with a narrative about the global health scene — its proponents, ideas and controversies. The articles will then take the reader on a journey from Harvard academia to unexpected health problems in a developing country, and then to Germany, where I am medical editor at Die Zeit, in Hamburg.

Why Germany? What connection exists between a developed and wealthy country such as Germany (with a life expectancy at birth of 78 years) and the desperate situation in a poor, developing nation like Uganda (life expectancy at birth 47 years)? For a long time diseases in Uganda have been tackled only in terms of public health; this meant that measures were not aimed at curing the individual but at treating large groups or even the whole population. (This strategy changed with the spread of antiretroviral medicines against HIV/AIDS.) However, in developed countries like Germany, where individual treatment is the dominant health approach used, the broader view of the whole population has been lost. But irrational and unhealthy behaviors, scarce resources, inequality and misdirected priorities are not only challenges for the developing world. Lessons learned in Uganda will illuminate failures of a developed health system like the one in Germany. As Rudolf Virchow, the German pioneer of social medicine, observed in 1848, "If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life."

Making the Abstract Real 

By David Kohn

Who deserves treatment more — the taxi driver in Sri Lanka with heart disease or the farmer in Zimbabwe with HIV? I’d never thought a lot about this question prior to this fellowship. But after taking several public health classes and discussing such issues with professors, colleagues and students, it’s one of the many topics I find fascinating about global public health. Issues involved with resource allocation are crucial. In an era when the Bill & Melinda Gates Foundation and others are donating billions of dollars to fight a range of deadly diseases, there is still not enough money to deal with all of the developing world’s health challenges. How should governments, aid organizations, and donors decide who gets what?

There is a controversy between vertical systems, which are health programs built by big donors to treat and prevent a single disease, and horizontal systems, which are health programs designed by countries (although often funded from abroad) to tackle a wide array of problems. Each approach has the potential to benefit different constituencies in different ways. Then there is "scalability," which is the potential for a given health program to be enlarged to reach an entire region or country, rather than the village that serves as a test case.

Such concerns fascinate public health researchers but are necessarily abstract. What I now regard as my challenge as a global health journalist is to make these important issues concrete for the average American reader, who will arrive at the story with no idea what scalability means and little interest in the vertical vs. horizontal debate. To do this requires that I find circumstances that exemplify these concepts and stories to tell of people whose lives offer testimony in these debates. My project will focus on inequities in health care among various groups in developing countries, as I also investigate how poor countries are working to build up their public health and hospital systems.

Africa: What Went Wrong? 

By Kondwani Munthali

Is it poverty? Is it the question of leadership? Who shoulders the blame for Africa’s health crisis — the multilateral agencies, foreign governments who provide both budget and development aid to African governments, or the World Health Organization, whose leadership has come under scrutiny and whose role is changing with the emergence of other potent players in global health? How can information be given to a 40-year-old African villager who does not know how to read or write? How can African men be convinced to use condoms or accept a daughter with AIDS? How does the need for an early prenatal clinic visit get explained to a 36-year-old woman who has had four deliveries at home or with a traditional birth attendant?

Questions and then more questions arise during a year at Harvard, where scientific, medical and public health scholars offer their accumulative years of knowledge and experiences in the field of global health. Here I’ve become acquainted with the social medicine and social justice approach of Paul Farmer, with economist Chris Murray’s discussion of the global burden of diseases and the vaccine trial discoveries, along with the all-you-need-to-know-about-AIDS authorities Max Essex and Saidi Kapiga, and the vast wealth of knowledge of Africa, its successes, failures and challenges. While many solutions and strategies have been proposed and tried, progress has been painstakingly slow. Maternal and child mortality continue to rise. Malaria remains the leading killer. AIDS has brought the already weak health systems to almost a total crash. Tuberculosis is mutating to becoming more resistant to antibiotics. And African leaders have decided to embark on academic debates about the link between HIV and AIDS while denying people treatments that are available.

Where does an African journalist fit? In the delicate balance between what is scientifically proven and the stories of the poor Africans, overwhelmed by the lack of life basics like food, clean water, and decent housing. In my reporting, I will seek to bring to my stories a series of voices — including those of people from the scientific, academic and technical communities — to evaluate Africa’s place in global health. I will narrate the perspectives of global health players about what has gone wrong in Africa.

Ultimately, my focus will settle on the political and economic authorities in Africa. I will travel from Congo, Brazzaville, the regional headquarters of the WHO in Africa, to visit key government and other stakeholders in Malawi, Zambia and Zimbabwe. Then, the voices of the poor — those bearing the burden of poor living conditions and inadequate health care on a daily basis — will be meshed with the thinking of these global health leaders in a search for answers to profound questions: What has gone wrong in Africa? And what solutions might emerge?

The fellowships in Global Health Reporting are supported by a three-year, $1.19 million grant from the Bill & Melinda Gates Foundation and are a joint initiative of the Nieman Foundation and Harvard’s School of Public Health. The initial pilot phase will run through 2009, when both the Nieman and the Gates Foundation will review its potential for endowment.

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