“For me, [multiple sclerosis (MS)] presented itself shortly after the birth of my second son. I had these symptoms; I had this profound fatigue that I didn’t have with my first child,” said Terrie Livingston at a recent Wilson Center event about the growing threat of non-communicable diseases (NCDs) on maternal health. Livingston is the Head of Patient Outcomes and Solutions at EMD Serono, a business of Merck KGaA, Darmstadt, Germany.
“MS primarily affects women, with the average age of diagnosis at about 33 years of age…when women are really thinking about having a family,” said Livingston. Livingston didn’t associate her symptoms with MS initially, and assumed they were due to either her recent pregnancy or the demands of caring for a newborn.
Pregnancy is an immunotolerant state, in which the immune system is able to tolerate a foreign substance, i.e. placenta and fetus. Due to changes in hormones, there are fewer relapses in MS patients who are pregnant, said Livingston. There is, however, a significant increase in the number and severity of relapses postpartum, she said. Symptoms of MS can be mistaken for other common symptoms of pregnancy, complicating diagnosis. In fact, it was about two years between the symptoms presenting and Livingston actually receiving the diagnosis of MS.
Misconceptions about the disease adversely impact a woman’s perception of her ability to become pregnant. Livingston recalled a time when physicians discouraged women with MS from having a family, telling them that it wouldn’t be possible. In fact, the U.S. has seen an increase in the prevalence of pregnancies in MS patients.
It’s important to raise awareness around race, disparities, and social determinants of health when it comes to MS and other non-communicable diseases, said Livingston. “Just like the changing face of the U.S., MS is also changing,” she said. What was once thought of as a disease that primarily affected Caucasian women, MS is now most prevalent in African American women. As an Asian American, Livingston attributes some of her delayed diagnosis to the fact that she’s “not the typical MS patient.”
Also lacking is an awareness of the links between MS and other chronic illnesses —like hypothyroidism, inflammatory diseases, hypertension, diabetes, and mood disorders. 40 to 60 percent of MS patients have mood disorders that include anxiety and depression. The heightened risk of other chronic co-morbidities is why it is important for individuals with MS to plan ahead when it comes to pregnancy, said Livingston. Pregnant women with MS need integrated care plans that are tailored to their needs based on where they are in their journey.
Since Livingston was diagnosed in 2006, the number of Disease-Modifying Therapies (DMTs) available for MS has increased from 4 to 17. “If you think about from 2006 to now, that’s 1 DMT that was approved every single year over the 13 and a half years,” she said. This gives providers and patients more options for treatment, but importantly, Livingston said, “it also gives patients hope.”
There is a “big opportunity” to provide education to patients with MS, and we need to continue addressing those unanswered tough questions, said Livingston. In her role as an MS patient advocate she is uniquely placed to drive research efforts and tackle topics around co-morbidities, symptom management, race, ethnicity, and healthcare disparities. “Living with MS, it has allowed me to impact people in a way that I could have never imagined,” said Livingston.
To address the security challenges facing Sub-Saharan Africa we need to shift the focus from a concept of state security to one of citizen security, says Ambassador Phillip Carter III (ret.), former Ambassador to the Ivory Coast and the Republic of Guinea, in this week’s Friday Podcast. “Our current strategy of a military response to terrorist organizations or criminal networks is inadequate at best, and probably unsustainable at worst,” says Carter. “To me, the greatest security threat in Africa is poor or bad governance.”
If you ask Africans what they perceive as threats to their security, terrorism isn’t at the top of their list, says Carter. “It’s dealing with corruption, it’s dealing with criminality, it’s making sure that their daughter can go to school without being assaulted, that their son can go to work without paying a bribe to a police officer.” Foreign policy has long operated in the realm of “state security”—investing in government institutions, militaries, and Ministries of Defense to promote security. “That needs to be challenged,” says Carter. “We find that many militaries are there to protect the regime, not necessarily the population.”
In addition to the military interventions focused on countering violent extremist organizations, “we need to look at the softer side of things,” says Carter. “Investing in issues like girls’ education, addressing the issue of gender inequality—these development objectives are actually security objectives. We know that high levels of gender inequality foster violence and we know that investing in girls’ education results in manifold increases with regard to GDP growth and prosperity that is inclusive. We know that when you empower women in a society, you are improving the sustainability of growth, of prosperity, of economic activity, and security.”
Supporting local institutions is critical to strengthening governance, says Carter, and a large part of that is ensuring that local organizations have the data and information to understand what their constituencies need. “I believe that good governance and democracy are social vaccines for a lot of things, but we have to engage in institutions that organizationally represent those values—they’re representative, they’re democratic in their structures, they’re inclusive, and they’re data driven,” said Carter. “If the assistance is driven out of Washington rather than out of the local community, it’s not going to be as effective as it could be.”
“If you live in the developed world or in some urban centers, then the supply of water is guaranteed,” said Gordon Mumbo, team leader for Sustainable Water for the Mara River Basin, a project of Winrock International and USAID’s Sustainable Water Partnership, in this week’s Water Stories podcast. When you wake up, you expect water to flow from your tap. “If you don’t find it flowing, you get upset and will probably call the utility company.” But people living in the Mara River Basin don’t have that luxury. “They have to walk to the river to get water and bring it home,” said Mumbo.
With the Sustainable Water Partnership project, Mumbo is working to make sure the Mara River keeps flowing and meets the demand for water. A cornerstone of the project is determining how much water is available and how much water the basin needs. Mumbo and his colleagues are working across Kenya and Tanzania on a water location plan that considers how much water is needed to sustain the environment, the people, and the wildlife, said Mumbo. Once they are able to identify the gaps between supply and demand, they will be better positioned to manage the river.
The project is also working to preserve the watershed by creating livelihoods that don’t require cutting trees and other vegetation. With a high demand for honey in the region, beekeeping has been one of their successful alternative livelihoods. “One would not want to cut down a tree where a beehive is kept,” said Mumbo.
When the Mara River Basin project started, there was no adequate platform for private investment, said Mumbo. He and his colleagues helped the private sector organize to invest in water management. For example, they registered a Mara Basin hoteliers association to facilitate their investment in water management to maintain the ecotourism industry. The hoteliers understand that the health of their business depends on the health of the Mara.
The government, meanwhile, needs to create an enabling environment that can attract investment from private investors. This involves creating a friendly policy environment, regulatory systems, access to financing, and sharing water information with the private sector and the general public.
When asked what the greatest lesson from the Sustainable Water Project has been, Mumbo said that gaining the public participation of stakeholders in water conservation was key. You must be able to share the data freely with stakeholders for them to understand how much water is available and when certain policies—like water managers sometimes asking farmers to stop irrigating—are necessary. This understanding and rapport is vital for the future as a rising population and a changing climate will only make the need for effective water management in the Mara River Basin greater.
The Wilson Center is partnering with the USAID Sustainable Water Partnership and Winrock International to share stories about global water security. The series has highlighted the connections between water and food security, water as a tool for resilience in times of crisis, and the challenges and opportunities of too little water, too much water, dirty water, and unpredictable water.
“Water point functionality goes beyond the mechanical structure of a pump,” says David DeArmey, Director of International Partnerships at Water for Good in this week’s Water Stories podcast. “Community dynamics play a role in how the water point is managed on a daily basis.”
After identifying where to place water access points in communities throughout the Central African Republic (CAR), Water for Good helps facilitate a series of workshops to engage local communities with WASH (Water, Sanitation, and Hygiene) training, financial and infrastructure management, and the importance of preventative maintenance. A regional representative from the Ministry of Hydraulics is also incorporated into the training workshops to help strengthen state presence and build a more resilient system. After the bore holes are drilled down to the water table and hand pumps are installed, the NGO performs regular preventative maintenance to replace pump parts that wear out over time to prevent mechanical failures.
A Volatile Context
Since achieving independence in 1960, the country never effectively established a state presence despite being vast, about the size of Texas, DeArmey said. Even basic infrastructure that one would expect for a country to function does not exist outside of the capital city of Bangui. For example, only 400 of the 15,000 miles of road are paved. “But beyond infrastructure, there is a chronic security issue,” he said. Chronic political instability led the country into its second civil war in 2012 with an unprecedented level of violence. Today, nearly 80 percent of the country’s territory is controlled by up to 14 different rebel factions.
Although it operates in a volatile context, Water for Good continues its work in CAR, performing preventative maintenance on water points. Since many of the technicians who inspect the pumps are Central Africans who understand the dangerous conditions on the ground, Water for Good is able to navigate safely throughout the country. Employing Central Africans and training them in the long-term maintenance program protects them. “The communities know them well and they are accepted even in times of insecurity,” said DeArmey.
Peacebuilding in a Complex Setting
“Having the capacity to drill wells, especially in times of conflict, can create unexpected opportunities,” said DeArmey. During the height of the conflict in 2014 and 2015, inter-community tensions caused major divisions between local Christian and Muslim communities. After the Muslim population fled the Lomi District, part of the city of Berberati, the neighborhood began to suffer from an “economic and social void.”
Because the Christian population wanted to ensure that the Muslims had a safe environment to return to within their neighborhood, they decided to create a new water point and invite the Muslim community to return and join them in managing it and sharing its water. “That Christian community served as an example in the rest of the city and beyond,” DeArmey said, “and it created a really positive environment in some of the darkest times of the country. So drilling a well in the Lomi District directly helped engage with peacebuilding in a very complicated setting.”
“Having a planet that is suitable for us has taken a very long time, like four and a half billion years,” said Sylvia Earle, Explorer in Residence at the National Geographic Society, in a podcast interview with Ambassador David Balton before a recent Wilson Center event on marine protected areas. “It’s taken us about four and a half decades to significantly unravel, deplete, [and] modify those precious systems that really have little margin of error.”
After decades of working in marine research and exploration, Earle noted that rapid technological development during the second half of the 20th century led to major discoveries in ocean science, possibly more than all preceding history. “Today, we’re beginning to engage technologies that will enable humans to experience the ocean as well as to deploy an incredibly growing array of sensors and devices to map the ocean,” she said.
However, despite our expanded understanding of marine science, ignorance poses the biggest challenge to oceans today, said Earle. “Why don’t people care about the ocean? Most people see it from the surface if they see it at all.” They miss the abundance of life in the ocean. Yet the ocean and its relationship to planetary processes is vitally important to our economy, security, health, and prosperity. The ocean is what keeps us alive. “No ocean, no life,” said Earle.
Despite what we now know about the nature of the world and what it takes to hold the planet steady, keeping the planet’s chemistry within safe limits, she said, we are perversely still “burdened with habits that are born of a time” when we did not fully understand the fragility of the earth. Humans are still changing the earth’s temperature, shifting the chemistry of the air and water, and slaughtering wildlife. Especially in the ocean, the scale of this degradation is unprecedented, she said.
We still have policies created when we thought that the ocean was too big to fail. Laws and policies still allow the legal extraction of large quantities of wildlife from the ocean, sending the message that it is okay to do things even though they are really threatening our existence. Protecting nature must no longer be optional, but rather our highest priority, she said. If we fail to stabilize the way the natural systems function, nothing else matters, she said.
We must do everything we can to “give nature a break,” said Earle. We must embrace critical natural areas that are still in good shape to ensure that they remain in good condition, and we must do everything we can to restore areas that have already been depleted or damaged. “It makes sense to at least identify some of the most critical areas and embrace them with care,” she said. “That’s not a lot to ask. In fact, I think we are asking too little.” Quoting Chilean President Sebastián Piñera, Earle said, “We are of the first generation to know what the problems are, and we are the last generation to be able to do something about it.”
“When you're in a post-conflict phase, it means we really should be moving away from humanitarian assistance into development because we've moved along the conflict spectrum toward peace and development,” said Erika Weinthal, the Lee Hill Snowdon Professor of Environmental Policy at Duke University, in this week’s Water Stories podcast.
A problem arises, Weinthal said, when you don't recognize that conflict is still going on.
Humanitarian vs. Development Responses
In many conflict settings, the humanitarian and development community both try to provide aid to those in need. However, they often work at odds with one another, she said. The humanitarian sector focuses on addressing immediate needs by providing basic services and access to potable water. Meanwhile the development sector aims to build lasting infrastructure and foster sustainable, long-term, prosperity.
Aid communities should be careful about the terminology they use when referring to various stages of conflict, she said. Using the term “post-conflict” comes with implications because it mandates a particular type of intervention. “The global community has often said Afghanistan is post-conflict, Iraq is post-conflict, but the empirical reality on the ground is that there is a lot of conflict still going on,” she said. Where a protracted humanitarian crisis still festers, development actors on the ground, she said, must recognize that what may be the most beneficial in terms of restoring livelihoods is providing basic resources and access to water.
Weinthal has also tracked attacks on infrastructure in Iraq, Yemen, Syria, and Libya. Due to the changing nature of warfare, especially in the Middle East, both state and non-state actors are involved in conflicts. “You’re seeing a large number of groups that are vying for control,” she said. “It’s no longer a traditional war.” Therefore, different infrastructure is targeted at different times by different actors. In the early years of the Yemen conflict, there were many attacks on energy infrastructure. By 2015, we began seeing more attacks on water, agriculture, and health, she said.
Weinthal’s research focuses on the role water plays in active and protracted conflicts, specifically the consequences of targeting water systems and weaponizing water during war. One way water is weaponized is through “slow violence,” a process that unfolds gradually with such long-term effects that are so under the radar that they may seem invisible, such as restrictive government policies or contaminated natural resources. The oil contamination of the Niger River Delta and the displacement of people from large dams are examples of slow violence, said Weinthal.
A large part of her research focuses on the impact that the Israeli occupation has had on water access in the West Bank and Gaza. Israeli permit denials are preventing Palestinians from seeing new water infrastructure built, wastewater treatment systems installed, and new wells drilled, she said. We often don’t look at the long-term impacts on the ecosystem and on human well-being, she said.
“I’ve never seen this kind of political and public sector engagement in an environmental topic happen so fast,” said Rob Kaplan, the Founder and CEO of Circulate Capital in an interview with Ambassador David Balton following a recent Wilson Center event on reducing marine plastic pollution. Interest in reducing ocean plastics has gone from a blip on the radar at ocean conferences to “now becoming a top priority,” said Kaplan.
After working on sustainability initiatives in the private sector for roughly a decade, Kaplan transitioned to researching strategies to reduce ocean plastics. Eventually, he founded Circulate Capital, an investment management firm with two goals. “First, we want to invest in companies that prevent plastic pollution,” he said. These companies “collect, sort, process, and even manufacture using plastic waste that would ultimately otherwise end up in the environment.” The company also helps a variety of investors, in both the public and private sectors, allocate more capital to reduce marine plastic pollution.
Circulate Capital has already attracted more than $100 million in corporate investment from PepsiCo, Procter & Gamble, Coca-Cola, Unilever, Danone, and Dow. However, when it comes to making loans to recycling companies in regions of the world that are the largest producers of plastic pollution, Kaplan realized that the private sector could do only so much alone. “We’re working in really tricky geographies, where nobody has done this before, and that just equates to financial risk,” he said.
To absorb some of the risk and create a bigger impact together, Circulate Capital and USAID launched a new partnership. For every loan made to a recycling company in an emerging market, USAID provides a credit guarantee, thereby reducing the risk for corporate investors.
Galvanizing Political Will
The interest in fighting ocean plastics is growing both in the United States and internationally. Even in this immensely polarized time, the issue has bipartisan support on Capitol Hill, Kaplan noted. The Save Our Seas Act was one of the few pieces of bipartisan legislation passed by Congress last year, let alone passed unanimously. “The political will is there,” Kaplan said. “There is nobody really for plastic waste. It hasn’t become politicized.” At the Wilson Center event, Senator Whitehouse (D- RI) said that he and Senator Sullivan (R-AK) are working together on an even larger bill to protect the ocean.
Private sector companies are trying to be part of the solution, said Kaplan. “I think most companies agree that they don’t want their packaging ending up in the environment,” he said. “They don’t want animals eating it. They don’t want it polluting people’s waterways and their livelihoods on the ground in the communities where they’d like to do business.”
When asked what was next for the partnership, Kaplan said that his company plans to invest $100 million in companies in the next three or four years, demonstrate proof of concept, and attract more capital. Ultimately, he said, much more must be invested to combat ocean plastic pollution. “We need many billions of dollars deployed into this space as quickly as possible,” he said.
“When you get to the power of voice, you have to be brave and you have to be that person that will speak up and say this isn’t right, but I want to be a part of the solution,” said Eileen Martin, the Global Director of Inclusion at EMD Serono, the U.S. division’s biopharmaceutical arm, of Merck KGaA, Darmstadt, Germany. She spoke at a recent Wilson Center event on the intersections between women’s health, leadership, and economic prosperity. This edition of Friday Podcasts is led by Sarah B. Barnes, Project Director of the Maternal Health Initiative at the Wilson Center.
Healthy Women, Healthy Economies
When women are healthy, everyone benefits. When women are supported to fully contribute to national economies, again, everyone benefits. Often, the barriers women face toward economic participation are preventable with smart policies. The Healthy Women, Healthy Economies (HWHE) toolkit provides those policies and workplace strategies for hiring entities like governments, companies, and NGOs to encourage, integrate, and retain women in the workplace.
“Policy is key”, said Martin. Merck-Brazil used the policy toolkit to find both external and internal successes around improved women’s health and participation in the workforce. Internally, Merck-Brazil increased the number of women in leadership positions from 30 percent to 43 percent over a two year period. Externally, the toolkit aided the company in their work to bring awareness to the significance of colorectal cancer and to influence government and insurance policies to include recognition of and services for colorectal cancer, where previously only breast and cervical cancer were included.
The Balancing Act and Sponsorship
“Let’s forget about 9 to 5,” said Martin. Women tend to have a double and triple burden on a day-to-day basis that inhibits a normal work schedule and has women providing unpaid work way beyond a 40 hour work week. When employers implement policies and strategies to hire, maintain, and promote women in the workforce, a woman’s juggling act of balancing career, family, and health is relieved. “Let’s leverage technology and let’s really redefine what a ‘9 to 5’ day actually looks like.”
Martin stated that there is a lack of sponsorship for women in the workforce to support their progression. “Women tend to be over-mentored and under-sponsored,” she said and went on to explain, that while a mentor can really cheer on employees and be an advocate, they don’t have the political or the social capital to pull someone forward in the organization. A sponsor has to be somebody who can “put their political and social capital on the table and pound their fists” to demand that women in the workplace are given their rightful seat at the table.
Africa in Transition, a new series hosted by the Wilson Center and the Population Institute, explores the role of population trends—migration, urbanization, fertility, maternal mortality—in shaping sub-Saharan Africa’s chances for prosperity, health, and security. In this podcast, we share highlights from the first Africa in Transition event. Parfait Eloundou-Enyegue, Professor at Cornell University, starts the conversation by reminding us that “African countries are in the middle of multiple transitions that have the potential to create opportunities for prosperity, growth, and increased human capital, but also to create greater inequality. The challenge, therefore, is to build prosperity, but to do it for all.”
Dr. Gladys Kalema-Zikusoka, the founder and CEO of Conservation Through Public Health (CTPH) said that “the solutions to our problems can only be solved by us people in Africa.” What the international donor community can do to support those efforts is provide technical assistance and training. The solution has a lot to do with empowerment, she said.
The number of women in leadership positions is on the rise in Africa, said Musimbi Kanyoro, President of the Global Fund for Women. “There are women who understand the facts […] and they are speaking up and wanting more recognition and space, wanting more resources, wanting more funding and investing in their own families and their children.” This is especially evident with women’s involvement in the workplace. However, African women do not receive equal representation in governance. “When women are in leadership positions, you see other areas impacted as well.”
“Meaningful youth engagement […] is one of the most important things that we can do” to build a prosperous and goal-oriented society, said Unami Jeremiah, founder of Mosadi Global Trust. Intergenerational dialogue and thoughtful transition plans are critical to ensuring a secure future for countries in Sub-Saharan Africa.
To further empower women and youth, panelists highlighted the need to provide family planning and reproductive health services, and comprehensive sexuality education (CSE). In many cases, sexuality education programs are aimed solely at young people in school settings, said Jeremiah. To be effective, CSE must be shared with parents and caregivers, otherwise upon entering the home “one might as well leave their CSE at the door.” CSE is meant to teach people how to be safe and healthy, said Kanyoro, citing the influence of the Me Too movement on modern CSE. “It will make a difference in how we begin to tell the story of comprehensive sexuality education to everyone, because that is a human right.”
For more information on the Africa in Transition: Investing in Youth for Economic Prosperity event, please visit the event page.
Seeing the influx of international aid into Haiti following the 2010 earthquake, Dr. Florence Jean-Louis, Director of Human Development at Fonkoze, asked herself, “How can all this support, all this solidarity, stay in-country and have a real impact in the long-term?” She spoke at a recent Wilson Center event on the importance of community health systems to the sustainable development and stability of countries. The answer, she concluded, was to build the capacity of local organizations.
Case #1: Haiti and the Power of the Local Community
In Haiti, Fonkoze began as a small local organization with a grant from USAID. As a new organization, Fonkoze aimed to address sustainability by employing local community members, rather than professional foreign staff. “It took a lot of training, coaching, and consulting to get there,” said Dr. Jean-Louis. Using a volunteer-based strategy and grants from USAID and Advancing Partners & Communities (APC), Fonkoze has achieved a great deal of impact and positive health outcomes from nutrition, sanitation and hygiene, and other programs.
Case #2: Increasing Ebola Survivors’ Access to Care in Liberia
Liberia was one of the countries most affected by the Ebola crisis in 2014 and 2016. Those who survived the infection faced significant morbidity and challenges to their quality of life, including mental health problems and eye issues. “The focus of our work was on survivors, which including increasing access to specialty care,” said Dr. Rose Macauley, Chief of Party at APC Liberia. Funded by USAID, APC Liberia trained 60 mental health clinicians to meet the needs of Ebola survivors. Prior to this program, Liberia only had one psychiatrist for the 4.5 million people that lived there, said Macauley. Through the grant, APC also funded two faith-based institutions that care for survivors. More than 22 percent of the country’s Ebola survivors registered with them. APC also supported the development of the National Ebola Survivors’ Network of Liberia, a civil society organization that empowers survivors to recover, advocate for themselves, and integrate into their communities.
Case #3: Expanding Services for the Disabled in Laos
Millions of undetonated submunitions remain scattered throughout Laos since the Vietnam-American War. These explosives continue to be a source of danger and have caused thousands of accidental injuries and deaths since the end of the war. As a grantee of APC, World Education Laos implemented the TEAM (Training, Economic Empowerment, Assistive Devices, and Medical Rehabilitation) project, which gave out “$2.7 million dollars of grants in almost three years to 16 sub-grantees in Laos,” said James MacNeil, Vice President of World Education. These sub-grantees included the Cooperative Orthotic and Prosthetic Enterprise (COPE), as well as the Quality of Life Association (QLA), which are both local organizations dedicated to providing support and assistance to victims of unexploded ordnance (UXO) and people with disabilities to promote rehabilitation and sustainable livelihoods. As a result, these programs have made a significant impact in the disability sector in Laos.
Each speaker highlighted how partnerships between local organizations, international organizations and donors, and governments help communities respond to local challenges. These partnerships provide resources to support local organizations and solutions that build capacity to help countries become self-reliant. “Local organizations should be key actors in the work for sustainable development since they are the ones who stay, who strive, who sustain efforts with no termination date,” said Dr. Jean-Louis.