Friday Podcasts From ECSP and MHI

The past year brought not only an end to political instability in Madagascar but a new surge of interest in integrated population, health, and environment (PHE) development, says Caroline Savitzky of Blue Ventures in this week’s podcast. “Madagascar has a very wide range of habitats, both terrestrial and marine, and these are all experiencing significant degradation,” says Savitzky, a community health program coordinator with the London-based NGO. Eighty percent of the flora and fauna are found nowhere else in the world and there’s “very high dependence on natural resources among local communities.” “We’re also seeing a very significant unmet need for family planning. About three-quarters of a million women in Madagascar want to be able to plan their families but are not currently using modern methods of contraception,” Savitzky says. The country’s population is estimated to double by 2040. Blue Ventures started working in Madagascar focused on marine conservation along the southwest coast. But in response to an overwhelming demand for health services – in some communities people had to walk the length of a marathon to reach basic care, Savitzky says – they added reproductive health services to their natural resource management and livelihood programs. After seven years implementing this PHE approach, Savitzky says Blue Ventures has seen a five-fold increase in the number of women using contraceptives. In addition, communities have a stronger voice in managing their natural resources. Now Blue Ventures is replicating the model further north around Belo-sur-Mer, where they are reaching 10,000 people across 10 villages. They are also exploring the feasibility of bringing health services to communities in the remote Maintirano Barren Isles. In Andavadoaka, where Blue Ventures has been operating longest, Savitzky says they’ve begun a “realist evaluation” to learn why their approach has been successful. We’re now looking to prove both scalability and sustainability of these models and then of course transition to complete handover of these programs, so that they’re not just community-based programs but obviously completely community-led and community-driven programs. But most importantly, says Savitzky, Blue Ventures would like to help other organizations use the PHE approach. “We don’t see Blue Ventures as becoming this huge organization implementing PHE projects all over the place, but rather we see ourselves as being in a position to support other organizations, both large and small, that want to implement these models.” And there seems to be an audience for such support. This summer, representatives from 35 different development and conservation organizations – including the Duke Lemur Center and Marie Stopes, which started a new PHE program this year – met in Antananarivo to form a Madagascar PHE Network. Members agreed to work together to expand the integrated approach to development by exchanging technical knowledge and jointly engaging policymakers and donors. The new, democratically elected government – the first since 2006 – has also pledged its commitment to PHE, says Savitzky. And most importantly, there’s great support among the communities they work with. “This is an approach to sustainable development that meets [community] needs and the way they’re felt,” she says. “People don’t live their lives in silos; PHE addresses health, it addresses conservation, and livelihoods all together.” Savitzky spoke at the Wilson Center on October 14.  Friday podcasts are also available for download on iTunes.

Technological solutions, like improved equipment and logistical tools, have been trumpeted as keys to finally ending preventable maternal and child deaths. “But it’s not just technology innovation that we need; it is systems innovation,” says Dr. Harshad Sanghvi in this week’s podcast. Improving training for health workers is one of the best investments towards improving maternal and child health, says Sanghvi, vice president of innovation and medical director of the global health NGO Jhpiego. “One of the big challenges in our environment is not only acquiring the skills, but maintaining the skills,” he says. Through experience, Sanghvi says he’s learned that training doesn’t necessarily stick unless there’s follow-up and spot checks after the initial lesson: Imagine a frontline health worker who doesn’t often see postpartum hemorrhage, but when postpartum hemorrhage occurs, she’s got to be ready to do it. If you haven’t practiced a skill for a while, then that skill disappears. Giving health workers the chance to practice skills under the conditions they’re likely to be working under is also important. “Training them in big city nursing schools and midwifery schools is just not sufficient if we want them to practice in rural areas,” he says, and you can work with an entire team at once by going to where they are. Empowered Health Workers Are More Effective  Better tracking and health administration systems can help identify where knowledge gaps among staff have formed. In Nepal, for example, Jhpiego helped professional associations conduct a brief survey on how clinics screened for and treated preeclampsia which revealed a lack of understanding on how basic blood and protein tests can prevent the often-life threatening condition. Through phone calls, officials then monitored how workers and clinic administrators were implementing needed changes. “Using this combined approach, this blended approach of training as well as governance, actually has a better chance of making impact than just a training approach,” says Sanghvi. But the most effective training programs provide not only skills to health workers, but also the confidence and ability to deploy them, he says. In Afghanistan, Jpheigo partnered with local health officials to not only strengthen curricula in midwifery schools, but provide nursery and nanny services to the many students with children and teach English and computer skills so they could access a much wider range of information after schooling. One student from this program was able to perform a manual placenta removal – a very difficult procedure – on a patient who was bleeding heavily after labor and whose husband refused care for her three times before relenting. She did this despite knowing that failure might have cost her her life in such a patriarchal society. “She was empowered enough to stand up to this guy,” says Sanghvi, “and she was also empowered by the knowledge and the competency and the capability and the proficiency that she had.”  Sanghvi spoke at the Wilson Center on September 30. Friday podcasts are also available for download on iTunes.

Technological solutions, like improved equipment and logistical tools, have been trumpeted as keys to finally ending preventable maternal and child deaths. “But it’s not just technology innovation that we need; it is systems innovation,” says Dr. Harshad Sanghvi in this week’s podcast. Improving training for health workers is one of the best investments towards improving maternal and child health, says Sanghvi, vice president of innovation and medical director of the global health NGO Jhpiego. “One of the big challenges in our environment is not only acquiring the skills, but maintaining the skills,” he says. Through experience, Sanghvi says he’s learned that training doesn’t necessarily stick unless there’s follow-up and spot checks after the initial lesson: Imagine a frontline health worker who doesn’t often see postpartum hemorrhage, but when postpartum hemorrhage occurs, she’s got to be ready to do it. If you haven’t practiced a skill for a while, then that skill disappears. Giving health workers the chance to practice skills under the conditions they’re likely to be working under is also important. “Training them in big city nursing schools and midwifery schools is just not sufficient if we want them to practice in rural areas,” he says, and you can work with an entire team at once by going to where they are. Empowered Health Workers Are More Effective  Better tracking and health administration systems can help identify where knowledge gaps among staff have formed. In Nepal, for example, Jhpiego helped professional associations conduct a brief survey on how clinics screened for and treated preeclampsia which revealed a lack of understanding on how basic blood and protein tests can prevent the often-life threatening condition. Through phone calls, officials then monitored how workers and clinic administrators were implementing needed changes. “Using this combined approach, this blended approach of training as well as governance, actually has a better chance of making impact than just a training approach,” says Sanghvi. But the most effective training programs provide not only skills to health workers, but also the confidence and ability to deploy them, he says. In Afghanistan, Jpheigo partnered with local health officials to not only strengthen curricula in midwifery schools, but provide nursery and nanny services to the many students with children and teach English and computer skills so they could access a much wider range of information after schooling. One student from this program was able to perform a manual placenta removal – a very difficult procedure – on a patient who was bleeding heavily after labor and whose husband refused care for her three times before relenting. She did this despite knowing that failure might have cost her her life in such a patriarchal society. “She was empowered enough to stand up to this guy,” says Sanghvi, “and she was also empowered by the knowledge and the competency and the capability and the proficiency that she had.”  Sanghvi spoke at the Wilson Center on September 30. Friday podcasts are also available for download on iTunes.

Leaders from around the world gathered in New York last month to discuss the replacements for the Millennium Development Goals, which expire next year. The topics included human rights, economic development, justice, disarmament, and terrorism, just to name a few. And that’s a problem, says Genevieve Maricle, policy adviser to the U.S. Ambassador at the U.S. Mission to the UN, in this week’s podcast. “There are so many really good arguments for why thousands of issues need to be part of this agenda,” Maricle says. “That’s one reason we ended up with 169 targets and 17 goals; it’s because this isn’t an easy question.” But focus is badly needed. She cites an example of the current goal to combat HIV/AIDS, tuberculosis, and malaria, which was kept in the next round of goals, but in the “eleventh and a half hour, [the working group] added, ‘and other communicable diseases.’ So now we are left with a target that literally takes on every disease that the world faces.” “We as a community, both civil society and government and private sector, know how to do better than that,” she says, “and we have to hold ourselves to be more precise than that, to be more rigorous in how we set our own priorities.” Integrating Goals? Prioritization is instrumental to creating a development agenda that is manageable, measurable, and actionable, Maricle says. “We have to ask those questions about, ‘Who are the right actors and how do we determine an agenda that’s based on that, and how do we know that not putting something in this agenda doesn’t mean we don’t care about it?’” Some criteria for focus were discussed at the Rio+20 Conference in 2012, which concluded that goals should be limited in number, universally relevant, action-oriented, and easy to communicate. But Maricle says that there’s still more to do to make the post-2015 goals manageable. It’s critical what’s included is measurable and achievable, for example. “If we do a thorough analysis of the evidence base of it, what do we end up with as the answers for what we can actually effect change on?” Combining goals could help make things more manageable. “Our goal isn’t to figure out which aren’t important,” Maricle says. “Our goal is to figure out how to either integrate or consolidate ideas to bring them together and collectively get to action…or it’s to figure out what we’re most effective at.” For example, drawing from her experience working on issues of peace and governance, Maricle cites a UNESCO study that estimates more than 28 million children are not in school in countries that are emerging from conflict. “If we’re going to set a goal that says we are going to get to universal primary education, we will not get there if we don’t deal with issues of conflict and of peace,” she says. Integrating targets on peace and governance into the goal of achieving universal primary education could mean that more students are able to go to school. A Turn to Multilateralism Focusing also requires a discussion about which goals should be the burden of governments and which should be the responsibility of other organizations, Maricle says. “We have to be able to know that we can have another system, or a system that’s complementary to this, to flag critical issues without needing to have them be part of this.” The concept of multilateralism is really the crux of the post-2015 development agenda, she says. “You can’t achieve any of these complex things without it being about cooperation.” This cooperation includes not only state actors, but also civil society and private sector engagement. Ultimately, the future of multilateralism and the role of the UN will be tested by the success or failure(continued)

Leaders from around the world gathered in New York last month to discuss the replacements for the Millennium Development Goals, which expire next year. The topics included human rights, economic development, justice, disarmament, and terrorism, just to name a few. And that’s a problem, says Genevieve Maricle, policy adviser to the U.S. Ambassador at the U.S. Mission to the UN, in this week’s podcast. “There are so many really good arguments for why thousands of issues need to be part of this agenda,” Maricle says. “That’s one reason we ended up with 169 targets and 17 goals; it’s because this isn’t an easy question.” But focus is badly needed. She cites an example of the current goal to combat HIV/AIDS, tuberculosis, and malaria, which was kept in the next round of goals, but in the “eleventh and a half hour, [the working group] added, ‘and other communicable diseases.’ So now we are left with a target that literally takes on every disease that the world faces.” “We as a community, both civil society and government and private sector, know how to do better than that,” she says, “and we have to hold ourselves to be more precise than that, to be more rigorous in how we set our own priorities.” Integrating Goals? Prioritization is instrumental to creating a development agenda that is manageable, measurable, and actionable, Maricle says. “We have to ask those questions about, ‘Who are the right actors and how do we determine an agenda that’s based on that, and how do we know that not putting something in this agenda doesn’t mean we don’t care about it?’” Some criteria for focus were discussed at the Rio+20 Conference in 2012, which concluded that goals should be limited in number, universally relevant, action-oriented, and easy to communicate. But Maricle says that there’s still more to do to make the post-2015 goals manageable. It’s critical what’s included is measurable and achievable, for example. “If we do a thorough analysis of the evidence base of it, what do we end up with as the answers for what we can actually effect change on?” Combining goals could help make things more manageable. “Our goal isn’t to figure out which aren’t important,” Maricle says. “Our goal is to figure out how to either integrate or consolidate ideas to bring them together and collectively get to action…or it’s to figure out what we’re most effective at.” For example, drawing from her experience working on issues of peace and governance, Maricle cites a UNESCO study that estimates more than 28 million children are not in school in countries that are emerging from conflict. “If we’re going to set a goal that says we are going to get to universal primary education, we will not get there if we don’t deal with issues of conflict and of peace,” she says. Integrating targets on peace and governance into the goal of achieving universal primary education could mean that more students are able to go to school. A Turn to Multilateralism Focusing also requires a discussion about which goals should be the burden of governments and which should be the responsibility of other organizations, Maricle says. “We have to be able to know that we can have another system, or a system that’s complementary to this, to flag critical issues without needing to have them be part of this.” The concept of multilateralism is really the crux of the post-2015 development agenda, she says. “You can’t achieve any of these complex things without it being about cooperation.” This cooperation includes not only state actors, but also civil society and private sector engagement. Ultimately, the future of multilateralism and the role of the UN will be tested by the success or failure(continued)

When it comes to sustainable development, not all goals are created equal, says Wael Hmaidan, the director of Climate Action Network International, in this week’s podcast. Climate change “intersects everything we do,” he says, but is underrepresented in the Sustainable Development Goals (SDGs), a global development agenda being drafted to replace the Millennium Development Goals next year. When the SDG negotiation process began, “there was really no interest in climate change,” he says, “and there was a deep lack of understanding on the climate change issue and its implication for poverty and development in general.” That is changing, and now goal 13 (of 17) calls for countries to “take urgent action to combat climate change and its impacts.” But this is not enough, says Hmaidan. He argues for rephrasing goal 13, improving the targets for reaching it, and integrating climate change into other goals. Hmaidan also fears that the climate goal could be dropped, as others wish to reduce the total number of SDGs. This would undermine the credibility of the entire system, he says. “We cannot imagine a sustainable development agenda in this time and age that doesn’t include a climate goal.” “The Existential Issue” Climate change is “the existential issue on the table that can affect the survival of human civilization,” says Hmaidan. And while those working on climate change policy may recognize the scope and severity of the problem, the rest of the world doesn’t. “When you go outside of the climate bubble, which is the UNFCCC and such fora, and you come to another forum, this understanding of climate change doesn’t exist.” “To change everything, we need everyone,” he says, evoking last month’s People’s Climate March, which brought 400,000 activists to New York to urge leaders to take stronger action on climate change ahead of the UN General Assembly. The importance of having climate change be moved from an environmental problem to become a developmental, and even an existential issue, has to be understood by governments and communities around the world – this is the only way to solve it. Complementing the UNFCCC Some question the inclusion of climate in the SDGs out of concern that it will interfere with the UN Framework Convention on Climate Change (UNFCCC) process, which aims to produce a binding international agreement. But the SDGs need not conflict, says Hmaidan, and can actually complement the UNFCCC. Unlike UNFCCC agreements, the SDGs will not be legally binding, so their effectiveness hinges on their ability to “move feelings.” Language around climate in the SDGs should eschew the “technical” and “diplomatically crafted” style of the UNFCCC, he says, and instead strive to be “inspirational and aspirational,” capturing the spirit of the climate movement. He advocates for a more strongly worded climate goal, such as, “achieve zero net greenhouse gas emissions as soon as possible.” While the SDGs themselves should be far-reaching and inspiring, Hmaidan suggests getting more specific for the targets that make up each goal. The targets for the climate goal should address issues that aren’t covered in the UNFCCC process, like low-carbon development plans and national legislation, he says, and the targets for the energy goal ("ensure access to affordable, reliable, sustainable, and modern energy for all") should be more concrete and ambitious to complement the climate goal. Overall, the targets should be structured to draw out connections between climate change and other development areas, he says. “We cannot look at each goal separately; we need to look at how each of the goals interact with each other.” The post-2015 sustainable development agenda of(continued)

When it comes to sustainable development, not all goals are created equal, says Wael Hmaidan, the director of Climate Action Network International, in this week’s podcast. Climate change “intersects everything we do,” he says, but is underrepresented in the Sustainable Development Goals (SDGs), a global development agenda being drafted to replace the Millennium Development Goals next year. When the SDG negotiation process began, “there was really no interest in climate change,” he says, “and there was a deep lack of understanding on the climate change issue and its implication for poverty and development in general.” That is changing, and now goal 13 (of 17) calls for countries to “take urgent action to combat climate change and its impacts.” But this is not enough, says Hmaidan. He argues for rephrasing goal 13, improving the targets for reaching it, and integrating climate change into other goals. Hmaidan also fears that the climate goal could be dropped, as others wish to reduce the total number of SDGs. This would undermine the credibility of the entire system, he says. “We cannot imagine a sustainable development agenda in this time and age that doesn’t include a climate goal.” “The Existential Issue” Climate change is “the existential issue on the table that can affect the survival of human civilization,” says Hmaidan. And while those working on climate change policy may recognize the scope and severity of the problem, the rest of the world doesn’t. “When you go outside of the climate bubble, which is the UNFCCC and such fora, and you come to another forum, this understanding of climate change doesn’t exist.” “To change everything, we need everyone,” he says, evoking last month’s People’s Climate March, which brought 400,000 activists to New York to urge leaders to take stronger action on climate change ahead of the UN General Assembly. The importance of having climate change be moved from an environmental problem to become a developmental, and even an existential issue, has to be understood by governments and communities around the world – this is the only way to solve it. Complementing the UNFCCC Some question the inclusion of climate in the SDGs out of concern that it will interfere with the UN Framework Convention on Climate Change (UNFCCC) process, which aims to produce a binding international agreement. But the SDGs need not conflict, says Hmaidan, and can actually complement the UNFCCC. Unlike UNFCCC agreements, the SDGs will not be legally binding, so their effectiveness hinges on their ability to “move feelings.” Language around climate in the SDGs should eschew the “technical” and “diplomatically crafted” style of the UNFCCC, he says, and instead strive to be “inspirational and aspirational,” capturing the spirit of the climate movement. He advocates for a more strongly worded climate goal, such as, “achieve zero net greenhouse gas emissions as soon as possible.” While the SDGs themselves should be far-reaching and inspiring, Hmaidan suggests getting more specific for the targets that make up each goal. The targets for the climate goal should address issues that aren’t covered in the UNFCCC process, like low-carbon development plans and national legislation, he says, and the targets for the energy goal ("ensure access to affordable, reliable, sustainable, and modern energy for all") should be more concrete and ambitious to complement the climate goal. Overall, the targets should be structured to draw out connections between climate change and other development areas, he says. “We cannot look at each goal separately; we need to look at how each of the goals interact with each other.” The post-2015 sustainable development agenda of(continued)

The U.S. military has historically relied on its capacity for technological innovation to respond to new risks and crises. But, as Sharon Burke explains in this week’s podcast, the Pentagon has had to invent not only new technology, but a new role for itself in response to a changing world. Burke, who served as the first assistant secretary of defense for operational energy from 2010 to May 2014 and is now with the New America Foundation, explains that when she started working at the Pentagon 20 years ago, oil prices were low and she struggled to find space to pursue energy security. As the threats of the Cold War faded, however, the mission and role of defense agencies quickly became more complex and understandings of national security shifted. “Is security getting our kids to school and food on the table,” asks Burke. “What prevents us from doing that? Or are you talking about military security and defense threats that require a weapon to counter?” The Department of Defense now considers longer-term trends that can lead to instability and situations where they might be called on to respond – “systemic-level influences, where it’s gender and demographics and resources and military security all coming together,” she says. Military leaders must ask, “What‘s that going to look like? And what do we need to live in that world? Because if we don’t start building it now, we won’t have it.” Environmental change is among these global trends. The military’s signature strategy document, the Quadrennial Defense Review, incorporates climate change, energy security, and water, and the latest National Intelligence Strategy, released last week, includes a section on natural resources and frames climate change as a “threat multiplier.” The Department of Defense has also started to prioritize internal energy security. Burke’s former office, which she helped create, works to reduce costs and risks by managing energy use. Adaptability a Virtue As the forces shaping national security become more complex, so do the choices facing the military. For example, although alleviating poverty is not a military responsibility, says Burke, reconstruction teams in Afghanistan and Iraq had to confront poverty to try to stabilize the areas they worked in. “[The military] understand[s] that all of those questions have to be asked,” she says, “it’s the ‘then what?’ that gets more complicated, and I’m not sure that’s a bad thing, because the truth is there’s not always a military answer to a security challenge.” For Burke, finding the right answers also depends on a more dynamic political system. She says she worries about a “brittle, inflexible, and rigid political system” that’s not adapting to major changes on the world stage, like climate change and demographic shifts. These attributes are critical not only to protecting the United States, but also to maintaining its leadership role in the world. “We’ve proven to be a very resilient country ourselves, politically, over hundreds of years, but we seem to be at an unusual juncture,” she says. “Are we going to be able to continue to play that role going forward, and are we going to be able to marshal what we need to at home?”

The U.S. military has historically relied on its capacity for technological innovation to respond to new risks and crises. But, as Sharon Burke explains in this week’s podcast, the Pentagon has had to invent not only new technology, but a new role for itself in response to a changing world. Burke, who served as the first assistant secretary of defense for operational energy from 2010 to May 2014 and is now with the New America Foundation, explains that when she started working at the Pentagon 20 years ago, oil prices were low and she struggled to find space to pursue energy security. As the threats of the Cold War faded, however, the mission and role of defense agencies quickly became more complex and understandings of national security shifted. “Is security getting our kids to school and food on the table,” asks Burke. “What prevents us from doing that? Or are you talking about military security and defense threats that require a weapon to counter?” The Department of Defense now considers longer-term trends that can lead to instability and situations where they might be called on to respond – “systemic-level influences, where it’s gender and demographics and resources and military security all coming together,” she says. Military leaders must ask, “What‘s that going to look like? And what do we need to live in that world? Because if we don’t start building it now, we won’t have it.” Environmental change is among these global trends. The military’s signature strategy document, the Quadrennial Defense Review, incorporates climate change, energy security, and water, and the latest National Intelligence Strategy, released last week, includes a section on natural resources and frames climate change as a “threat multiplier.” The Department of Defense has also started to prioritize internal energy security. Burke’s former office, which she helped create, works to reduce costs and risks by managing energy use. Adaptability a Virtue As the forces shaping national security become more complex, so do the choices facing the military. For example, although alleviating poverty is not a military responsibility, says Burke, reconstruction teams in Afghanistan and Iraq had to confront poverty to try to stabilize the areas they worked in. “[The military] understand[s] that all of those questions have to be asked,” she says, “it’s the ‘then what?’ that gets more complicated, and I’m not sure that’s a bad thing, because the truth is there’s not always a military answer to a security challenge.” For Burke, finding the right answers also depends on a more dynamic political system. She says she worries about a “brittle, inflexible, and rigid political system” that’s not adapting to major changes on the world stage, like climate change and demographic shifts. These attributes are critical not only to protecting the United States, but also to maintaining its leadership role in the world. “We’ve proven to be a very resilient country ourselves, politically, over hundreds of years, but we seem to be at an unusual juncture,” she says. “Are we going to be able to continue to play that role going forward, and are we going to be able to marshal what we need to at home?”

Adolescent boys are 75 percent more likely to die from HIV/AIDS than girls. Why? That’s unclear. Lack of data and failure to engage boys in discussions about sexual and reproductive health and HIV care has left many suffering, says Elizabeth Berard, a health science specialist with the U.S. Agency for International Development, in this week’s podcast. While preparing to speak at the Wilson Center, Berard says she was struck by how little information is available about adolescent boys with HIV/AIDS. A 2012 report from UNICEF states that of the 2.2 million adolescents (between 10 and 19 years old) living with HIV, approximately 870,000 of them are boys. And that’s about it. Not only is there little data overall, but what is collected has not been aggregated, she says. “There are a variety of different numbers that are floating out there, some for 15 to 19 years old, some for 15 to 24 year olds, others that are just somewhere in between.” Different Genders, Different Needs Addressing this data gap is key. Berard notes that adolescent boys living with HIV are more likely to have been infected at birth and as a result face different challenges than adolescents who have contracted HIV behaviorally (many young girls contract the disease from their partners – new infection rates for women between 15 and 24 years old are double that of men). Adolescent boys also have fewer ways to access care. “Many women, regardless of age, find out they’re living with HIV only because of antenatal care,” Berard says. That leaves young boys with fewer opportunities to get tested and receive treatment. Cultural, religious, and traditional norms in many places limit the ability of young people to have open conversations about sexual and reproductive health generally, Berard says. This has a significant impact on their understanding of HIV transmission and care as well as the need to adhere to strict treatment regimens. In 2013, only 29 percent of youth in 157 countries had comprehensive knowledge of HIV/AIDS, according to the Population Reference Bureau. Improving HIV outreach and treatment for adolescent boys requires unique programs that engage boys in conversations about sexual and reproductive health in culturally and youth-appropriate ways, Berard says. She suggests a variety of interventions to get more boys into clinics, including family testing, voluntary male medical circumcision, couples’ testing, and targeting specific vulnerable groups, such as orphans, young men who have sex with men, and adolescents diagnosed with tuberculosis or malnutrition, which could be symptoms of HIV infection. Berard spoke at the Wilson Center on July 30. Download her slides to follow along. Friday podcasts are also available for download on iTunes.

Adolescent boys are 75 percent more likely to die from HIV/AIDS than girls. Why? That’s unclear. Lack of data and failure to engage boys in discussions about sexual and reproductive health and HIV care has left many suffering, says Elizabeth Berard, a health science specialist with the U.S. Agency for International Development, in this week’s podcast. While preparing to speak at the Wilson Center, Berard says she was struck by how little information is available about adolescent boys with HIV/AIDS. A 2012 report from UNICEF states that of the 2.2 million adolescents (between 10 and 19 years old) living with HIV, approximately 870,000 of them are boys. And that’s about it. Not only is there little data overall, but what is collected has not been aggregated, she says. “There are a variety of different numbers that are floating out there, some for 15 to 19 years old, some for 15 to 24 year olds, others that are just somewhere in between.” Different Genders, Different Needs Addressing this data gap is key. Berard notes that adolescent boys living with HIV are more likely to have been infected at birth and as a result face different challenges than adolescents who have contracted HIV behaviorally (many young girls contract the disease from their partners – new infection rates for women between 15 and 24 years old are double that of men). Adolescent boys also have fewer ways to access care. “Many women, regardless of age, find out they’re living with HIV only because of antenatal care,” Berard says. That leaves young boys with fewer opportunities to get tested and receive treatment. Cultural, religious, and traditional norms in many places limit the ability of young people to have open conversations about sexual and reproductive health generally, Berard says. This has a significant impact on their understanding of HIV transmission and care as well as the need to adhere to strict treatment regimens. In 2013, only 29 percent of youth in 157 countries had comprehensive knowledge of HIV/AIDS, according to the Population Reference Bureau. Improving HIV outreach and treatment for adolescent boys requires unique programs that engage boys in conversations about sexual and reproductive health in culturally and youth-appropriate ways, Berard says. She suggests a variety of interventions to get more boys into clinics, including family testing, voluntary male medical circumcision, couples’ testing, and targeting specific vulnerable groups, such as orphans, young men who have sex with men, and adolescents diagnosed with tuberculosis or malnutrition, which could be symptoms of HIV infection. Berard spoke at the Wilson Center on July 30. Download her slides to follow along. Friday podcasts are also available for download on iTunes.

What exactly is meant by “water security?” Different conceptualizations of the problem can lead to different, possibly misguided, solutions, says Coleen Vogel in this week’s podcast. Vogel, a professor at the University of Pretoria and a lead author of the IPCC’s 4th and 5th assessment reports, calls for reframing the water security discourse in three key ways. Water as Productive and Destructive The first step is to agree on a starting point for discussion. “If we don’t have a common kind of understanding I think we could do maladaptation and not just adaptation,” she says. Vogel advocates for the definition of water security introduced in a 2007 paper by David Grey and Claudia Sadoff: The availability of an acceptable quantity and quality of water for health, livelihoods, ecosystems, and production, coupled with an acceptable level of water-related risks to people, environments, and economies. This framing looks beyond the need to ensure adequate supplies and recognizes that water can also be a destructive force, she says. “It’s not just about the absence of water, but it’s also about the presence of water.” The multifaceted nature of water is captured in Grey and Sadoff’s typology of the “three H’s,” says Vogel, which suggests that wealthy countries have been able to “harness” water’s productive potential, while middle-income countries are “hampered” by hydrology and low-income countries are “held hostage” to it. Climate Change’s Distorting Effect Second, divergent understandings of climate change can hinder progress toward water security, she says. “We need to be framing the climate change discourse in this bigger thing called water security.” Analyses of climate change often emphasize long-term trends and overall changes in water supply, but the more urgent concern is actually variability, she says. Rapid and unpredictable changes pose a more immediate threat and are harder for societies to absorb. “Your institutional design can’t really cope if your rate of change is being exceeded too quickly.” Focusing too much on distant projections can also impede responses, says Vogel: I’ve been party to so many discussions where my well-meaning climatology friends and meteorologists come into the room and they run the simulation, the GCM models, and they switch it on and by 2070 the whole of Africa is red. And it just gets redder and redder, and you can look around the room and everyone is kind of feeling very uneasy... It’s marginalizing, because you lose your sense of agency because you think, ‘well I just can’t do anything about it.’ Technological Change vs. Social and Institutional Change Third, the “solution space” must be expanded, says Vogel. Technological solutions to water problems are only one part of the equation but often receive disproportionate attention. “If you only look at dam storage and hydropower from that perspective and you miss out all the power dynamics that go into moving people to design the dams and so on and so forth, you’re missing a whole huge wodge of stuff that you need to be including.” “We also need to be looking at the institutional space,” including water governance, laws, and pricing, she says. Water security cannot be achieved over the long term without integrating many different perspectives – including not only insights from across the social sciences, but also local and traditional knowledge, which often go overlooked. “Unless we open up that trans-disciplinary space really wide and fully, I don’t think we’re really going to do much,” says Vogel. “I think we’ll just be doing business as usual, spending a lot of USAID money.” Vogel spoke at the Wilson Center on August 20. Friday podc(continued)

What exactly is meant by “water security?” Different conceptualizations of the problem can lead to different, possibly misguided, solutions, says Coleen Vogel in this week’s podcast. Vogel, a professor at the University of Pretoria and a lead author of the IPCC’s 4th and 5th assessment reports, calls for reframing the water security discourse in three key ways. Water as Productive and Destructive The first step is to agree on a starting point for discussion. “If we don’t have a common kind of understanding I think we could do maladaptation and not just adaptation,” she says. Vogel advocates for the definition of water security introduced in a 2007 paper by David Grey and Claudia Sadoff: The availability of an acceptable quantity and quality of water for health, livelihoods, ecosystems, and production, coupled with an acceptable level of water-related risks to people, environments, and economies. This framing looks beyond the need to ensure adequate supplies and recognizes that water can also be a destructive force, she says. “It’s not just about the absence of water, but it’s also about the presence of water.” The multifaceted nature of water is captured in Grey and Sadoff’s typology of the “three H’s,” says Vogel, which suggests that wealthy countries have been able to “harness” water’s productive potential, while middle-income countries are “hampered” by hydrology and low-income countries are “held hostage” to it. Climate Change’s Distorting Effect Second, divergent understandings of climate change can hinder progress toward water security, she says. “We need to be framing the climate change discourse in this bigger thing called water security.” Analyses of climate change often emphasize long-term trends and overall changes in water supply, but the more urgent concern is actually variability, she says. Rapid and unpredictable changes pose a more immediate threat and are harder for societies to absorb. “Your institutional design can’t really cope if your rate of change is being exceeded too quickly.” Focusing too much on distant projections can also impede responses, says Vogel: I’ve been party to so many discussions where my well-meaning climatology friends and meteorologists come into the room and they run the simulation, the GCM models, and they switch it on and by 2070 the whole of Africa is red. And it just gets redder and redder, and you can look around the room and everyone is kind of feeling very uneasy... It’s marginalizing, because you lose your sense of agency because you think, ‘well I just can’t do anything about it.’ Technological Change vs. Social and Institutional Change Third, the “solution space” must be expanded, says Vogel. Technological solutions to water problems are only one part of the equation but often receive disproportionate attention. “If you only look at dam storage and hydropower from that perspective and you miss out all the power dynamics that go into moving people to design the dams and so on and so forth, you’re missing a whole huge wodge of stuff that you need to be including.” “We also need to be looking at the institutional space,” including water governance, laws, and pricing, she says. Water security cannot be achieved over the long term without integrating many different perspectives – including not only insights from across the social sciences, but also local and traditional knowledge, which often go overlooked. “Unless we open up that trans-disciplinary space really wide and fully, I don’t think we’re really going to do much,” says Vogel. “I think we’ll just be doing business as usual, spending a lot of USAID money.” Vogel spoke at the Wilson Center on August 20. Friday podc(continued)

With less than 500 days until they expire, it’s almost certain that the Millennium Development Goals on child mortality and maternal health will be missed by many countries. Already, work on drafting the MDG successors has begun; but unless policymakers put nutrition at the center of maternal and child health systems, reducing global maternal and child mortality ratios by an appreciable amount will be difficult, says Dr. Ranu Dhillon in this week’s podcast. “The issues of nutrition and health…sometimes get separated out when we talk at a policy level,” says Dhillon, a global health expert from Columbia University and Harvard Medical School who has worked on strengthening health care systems in India and other developing countries for more than a decade. Health system designs are “often premised on ‘how do we close the gap on MDG 4 and 5,” he says, which cover reducing the under-five mortality rate by two-thirds, reducing the maternal mortality by three-quarters, and achieving universal access to reproductive health. But “half of child deaths are driven by undernourishment,” he says, and malnutrition can have lasting implications for children that survive. In total, one-fourth of all children under 5 – 165 million children globally – are permanently stunted from malnutrition, says Dhillon. They face physical and cognitive deficiencies and vulnerability to disease and illness through adulthood. Limited cognitive development, for example, can lead to poorer education outcomes, which in turn can lead to a reduction in income potential – 22 percent on average, according to UNICEF. However, addressing malnutrition in children, as Dhillon says, requires paying more attention to mothers. As he illustrates through the story of Reena, a severely malnourished infant he encountered while on a site visit to a clinic in India, pregnant women who suffer from nutrient deficiencies are likely to pass them on to their children. This intergeneration cycle of malnutrition is fueled by economic and gender inequality and compounded by broken health systems. Poorer women like Reena’s mother lack the means and rights to attain food and care for themselves and their children, and the health facilities that they can access, are usually short on supplies, skills, and staff. Breaking the cycle starts with more effectively tackling nutrition issues, says Dhillon. Health systems should be reconfigured to offer “true primary health care” that addresses a broader spectrum of maternal and child health issues, particularly malnutrition, and does so proactively, rather than tackling problems after they’ve spiraled out of control. “Things Are Not Stuck the Way They Are” To build such a system, he explains, requires empowering mothers and health care providers. Care providers, from doctors to clinic staff to community mobilizers, should be equipped with the training to adequately treat patients, as well as maintain what Dhillon calls “organizational complexity” – managing multiple, interrelated interventions across health systems. As patients, mothers must be able to demand services and accountability from providers. He explains, for example, that Indian women in areas of high literacy, like Kerala state, “will not only meet the system halfway, they’ll show up at its door,” demanding proper services, whereas mothers like Reena’s have a general sense of their children’s health needs but are “not empowered to actually force the system to perform.” “Things are not stuck the way they are,” says Dhillon. “There’s enough people – poor and privileged – who see the ways things are as intolerable and unacceptable… When we start making the system reforms, I think you can have a virtuous cycle where the system reforms are actually reinforced by people actually being empowered and getting what they need and demanding [those services] to be there the next time.” Dhillon spoke at the Wilson Center on July 27. Friday podcasts are (continued)

With less than 500 days until they expire, it’s almost certain that the Millennium Development Goals on child mortality and maternal health will be missed by many countries. Already, work on drafting the MDG successors has begun; but unless policymakers put nutrition at the center of maternal and child health systems, reducing global maternal and child mortality ratios by an appreciable amount will be difficult, says Dr. Ranu Dhillon in this week’s podcast. “The issues of nutrition and health…sometimes get separated out when we talk at a policy level,” says Dhillon, a global health expert from Columbia University and Harvard Medical School who has worked on strengthening health care systems in India and other developing countries for more than a decade. Health system designs are “often premised on ‘how do we close the gap on MDG 4 and 5,” he says, which cover reducing the under-five mortality rate by two-thirds, reducing the maternal mortality by three-quarters, and achieving universal access to reproductive health. But “half of child deaths are driven by undernourishment,” he says, and malnutrition can have lasting implications for children that survive. In total, one-fourth of all children under 5 – 165 million children globally – are permanently stunted from malnutrition, says Dhillon. They face physical and cognitive deficiencies and vulnerability to disease and illness through adulthood. Limited cognitive development, for example, can lead to poorer education outcomes, which in turn can lead to a reduction in income potential – 22 percent on average, according to UNICEF. However, addressing malnutrition in children, as Dhillon says, requires paying more attention to mothers. As he illustrates through the story of Reena, a severely malnourished infant he encountered while on a site visit to a clinic in India, pregnant women who suffer from nutrient deficiencies are likely to pass them on to their children. This intergeneration cycle of malnutrition is fueled by economic and gender inequality and compounded by broken health systems. Poorer women like Reena’s mother lack the means and rights to attain food and care for themselves and their children, and the health facilities that they can access, are usually short on supplies, skills, and staff. Breaking the cycle starts with more effectively tackling nutrition issues, says Dhillon. Health systems should be reconfigured to offer “true primary health care” that addresses a broader spectrum of maternal and child health issues, particularly malnutrition, and does so proactively, rather than tackling problems after they’ve spiraled out of control. “Things Are Not Stuck the Way They Are” To build such a system, he explains, requires empowering mothers and health care providers. Care providers, from doctors to clinic staff to community mobilizers, should be equipped with the training to adequately treat patients, as well as maintain what Dhillon calls “organizational complexity” – managing multiple, interrelated interventions across health systems. As patients, mothers must be able to demand services and accountability from providers. He explains, for example, that Indian women in areas of high literacy, like Kerala state, “will not only meet the system halfway, they’ll show up at its door,” demanding proper services, whereas mothers like Reena’s have a general sense of their children’s health needs but are “not empowered to actually force the system to perform.” “Things are not stuck the way they are,” says Dhillon. “There’s enough people – poor and privileged – who see the ways things are as intolerable and unacceptable… When we start making the system reforms, I think you can have a virtuous cycle where the system reforms are actually reinforced by people actually being empowered and getting what they need and demanding [those services] to be there the next time.” Dhillon spoke at the Wilson Center on July 27. Friday podcasts are (continued)