On October 30, the Program on Human Rights (PHR) at Stanford's Center on Democracy, Development and the Rule of Law (CDDRL) held a day-long conference to examine health and human rights. The conference was held to discuss how a rights-based approach to health services can impact the delivery of effective health interventions and advance other socio-economic and cultural rights in developing regions. The conference titled, “Why We Should Care: Health and Human Rights” was divided into five panels with presenters from diverse backgrounds and professions including lawyers, doctors, public health experts, students and activists.

The Program:

The conference started with a welcoming address by Helen Stacy, director of the Program on Human Rights. CDDRL Director Larry Diamond introduced the keynote speaker Paul H. Wise, professor of child health and society and pediatrics at Stanford University’s School of Medicine, and director of the Center for Policy, Outcomes and Prevention. Wise's opening remarks began on a somber note, “The language of rights means very little to a child stillborn, an infant dying in pain from pneumonia or a child desiccated by famine.” In his address, Wise emphasized the need for an aligned and integrated rights-based approach that does not undermine effective and efficient medical interventions. “We need to fill the gap between the worlds of child health and child rights so that our programs and policies are both effective and just,” he stressed.

Following the keynote address, the conference presenters shared their work according to a geographic or thematic focus. The first panel brought together three generations of speakers from Stanford - a faculty member, a pre-doctoral fellow and a recent graduate - in a unique opportunity to share ideas and discuss possibilities of health work in Africa. Rebecca Walker, clinical instructor in emergency medicine at Stanford School of Medicine, presented her impressions and reactions on Mindy Roseman’s study of forced sterilization in Namibia. Roseman, academic director of the Human Rights Program and lecturer on law at Harvard Law School, was unable to attend due to flight complications after hurricane Sandy hit the East Coast.

Eric Kramon, 2011-2012 pre-doctoral fellow at CDDRL, spoke about the political sources of ethnic inequality in health outcomes in Africa.  Kramon’s work in Kenya illustrated how politics plays a determinant role in ethnic inequalities and consequently in access to health and health outcomes. Jeffrey Tran, a 2011 Stanford graduate in human biology, described the vision behind the launch of the Project of Emergency First Aid Responder in Western Cape Province, South Africa that he helped implement. Tran explained, “Individuals and communities are an integral part of the solution and we work with the communities to develop first aid training programs that are taught and eventually run by community members.”

Panel two was dedicated to the health impact of drones in Pakistan and in Gaza. Based on research by the Stanford International Clinic on Human Rights and Conflict Negotiation in Pakistan, Professor James Cavallaro and Stanford law school student Omar Shakir, explained that drones are not only responsible for deaths of civilians but also constitute a constant disturbance to social life and mental health of ordinary people, including their relations with children and the elderly. Drones impact other rights as well - such as the right to education - as children are prevented from attending schools for fear of drone strikes. Rajaie S. Batniji, resident physician in internal medicine at Stanford and a CDDRL affiliate, explained the clinical diagnosis of traumatic disorders that result from constant surveillance and insecurity. He cited the work of Jonathan Mann in defining dignity and the devastating effects on physical, mental, and social well-being when these senses are violated. Batniji explained that populations in Gaza are prevented from living life with dignity and respect because they live under constant threat to their security and intrusion into their homes and communications.

Vivek Srinivasan, manager of the Program on Liberation Technology at CDDRL, presented his experience on the Right to Food Campaign in India. He believes that this campaign has led to the mobilization for rights and the provision of services. “Not all demands are confrontational. Communities begin demanding something that is perceived as small in scope but have ramifications that extend to other rights such as the right to education, the right to housing and the right to work.” According to Srinivasan, the Right to Food Campaign in India has had a tremendous impact in putting hunger on the policy agenda. Suchi Pande, an activist-researcher who worked on the Right to Information Campaign in India for over seven years and was the secretary for the National Campaign for People’s Right to Information from 2006 to 2008, supported Srinivasan’s argument of strong correlation in achievements and right-based mobilization. However, Pande pointed out that despite successes in the Right to Food Campaign, other economic and social rights including the right to health in India continues to be a non-issue for politicians and the government. She is optimistic and believes that rural public hearings, the role of the right to information and its supporting mechanisms will facilitate access to public health in rural India.

In panel four, Sarah MacCarthy showed results that suggest that counseling and testing services for HIV-positive pregnant women remain limited, insufficient or lacking in quality in Salvador, Brazil. “While Brazil’s HIV/AIDS program has been internationally acclaimed, national practice still fails to meet national and global guidelines,” she explained. Calling attention to the regional discrepancies in the HIV/AIDS policy and program implementation in Brazil, Nadejda Marques, manager of the Program on Human Rights at CDDRL,, expressed concerns about the implementation of an HIV/AIDS program in a context of limited resources. “In Angola, counseling and voluntary testing units for HIV/AIDS don’t have drinking water or sanitary conditions to receive patients. They lack basic equipment for testing and data collection, there is a generalized shortage of doctors, and health care providers have no specific training on HIV/AIDS.” Despite this alarming situation, Marques explained that advocating for the rights of persons living with HIV/AIDS in Angola has put in evidence the failure of a heath system unable to provide even the most basic services to its population and has enabled mobilization in a context where human rights are routinely violated.

Ami Laws, adjunct associate professor of medicine at Stanford, described how a physician can provide services in collaboration with the judicial system to advance human rights. Laws is an expert witness on cases of torture survivors that require asylum status in the U.S. and has worked mainly with victims of torture in the Punjab region in India. Everaldo Lamprea, a JSD candidate at Stanford Law School and an assistant professor at Los Andes Law School in Bogotá, Colombia, spoke about his recent comparative study on health litigation in low and middle-income countries. The escalation of right-to-health litigation in these countries can have unexpected and harmful consequences to healthcare reforms and the enforceability of the right to health. In part, this is because significant financial resources are allocated to the litigation processes and not to the health system. In addition, while litigation can highlight gaps that exist in the health system that need regulation, countries have been very slow to adapt and adjust to these signals.

Next Steps:

A number of key ideas, questions and insights emerged from the conference including:

. How to identify an effective intervention that will also mobilize communities to advocate for its implementation?

. How to provide services to the more vulnerable populations without alienating a contingent that has access to basic health care services?

. What instruments can be used to share best practices among national healthcare systems?

. How do global priorities adapt to contexts of limited financial resources and human capital?

. How can punctual achievements in rights that guarantee access to health be expanded for the achievement of other social, economic and cultural rights?

The Program on Human Rights at CDDRL will continue to pursue a research agenda examining health and human rights following the conference and announced that it will be the thematic focus of the Sanela Diana Jenkins Speakers Series in 2014. The PHR is also actively seeking support for research projects that include a right to health component at the core of its academic investigation for the 2012-2013 academic year.

NAIROBI, Kenya – Single-room shacks with mud walls, metal roofs and dirt floors sleep families of eight here. Plastic bags filled with human waste are thrown into unpaved streets, earning the nickname “flying toilets." Trash piles up in front of homes and storefronts. The flies are everywhere. People struggle to survive but the appetite for change is strong.

This is Kibera, Nairobi’s largest slum home to hundreds of thousands packed onto one square mile of land. Kibera's population is a matter of debate – and politics – with unofficial estimates ranging from 250,000 to 1 million.

And it is next door to some of the city's wealthiest neighborhoods. On its edge lies a golf course serving the elite, the lush green grass a stark contrast to the rusted metal roofs that clutter Kibera's skyline.

More than half of Nairobi's residents live in human settlements like Kibera. Photo Credit: Sarina Beges

The government says those who live here are illegal squatters, and officials withhold basic public services like electricity, sewage and waste collection. Health care and education are expensive and out of reach for those struggling to find steady employment amid the rising price of food and fuel. Water is scarce here – a resource turned on and off by the government and a commodity overpriced by a handful of private dealers.

But mobile phones are so cheap and easy to access that more than 70 percent of people living in Kibera have one. Harnessing the potential of technology for development, an innovative course at Stanford is designing mobile phone applications to improve living conditions in Kenya's slums.

Incubating ideas

Stanford professors Joshua Cohen and Terry Winograd created Stanford's Designing Liberation Technologies course, which is taught at the Hasso Plattner Institute of Design (d.school) each spring. Grounded in the principle that an effective product cannot be designed without participation from the local community, the course pairs student teams with NGOs to co-create technology platforms.

"We started with the belief that by combining emerging mobile technologies with human-centered design, our students could find new opportunities to change people's lives for the better," says Winograd, a computer scientist. "We were fortunate to develop connections with strong local organizations that could guide our understanding of the needs and provide a vehicle for turning our students' ideas into real programs."

The course is part of the Program on Liberation Technology at the Center on Democracy, Development, and the Rule of Law (CDDRL) at Stanford’s Freeman Spogli Institute. Cohen and Winograd helped launch the program in 2009 with CDDRL Director Larry Diamond to explore how technology is being used to advance change in the developing world.

Originally funded with support by Nokia Research Center in Africa, the course is now supported by the Silicon Valley-based Omidyar Network.

One of the first ideas to come out of the class is M-Maji, which means “mobile water” in Swahili. M-Maji is a mobile application that uses a two-way SMS system to provide users with accurate and up-to-date information on the location, price and quality of one of Kibera's most precious resources – water.

Water economics

Water is scarce, expensive and can often be contaminated in Kibera. The government supplies water to Kibera just two or three days a week. When the water flows, vendors fill large hundred-gallon plastic storage tanks that tower imposingly from the rooftops.

A water tank sits atop a water vending station. Photo Credit: Sarina Beges

Water is collected from kiosks housed in storefronts along dusty streets and open gutters. Young girls pour water from rusty faucets into large jerrycans and struggle to carry the containers through Kibera's pock-marked streets. They spend about two hours a day collecting water for drinking, cooking, cleaning and bathing.

"On a good day they can go to their normal spot to find water, but on a bad day they have to keep walking around until they find a source," says M-Maji co-founder Sangick Jeon, a Stanford PhD student.

Jeon explains that water has turned into a big business in Kibera and large cartels deemed "the big five" control the price and availability of water, shutting out the smaller vendors from the marketplace. That means Kibera's residents pay more than double the cost for water than their rich neighbors on the other side of the golf course.

Water quality is always a concern.

"Most water is contaminated because steel pipes are stolen and they use above ground plastic pipes that break off and flying toilets can seep into the pipes," Jeon says.

Jeon is researching conflict and cooperation in Africa. He took the course taught by Cohen and Winograd two years ago and has stayed invested in M-Maji. He says Kibera is a fascinating place for a political scientist to work, but also points to the strong partnerships that have allowed the project to take root.

When asked about how the M-Maji technology works, Jeon laughs.

"I am just a political scientist," he says. "The guys at Umande Trust are doing it all."

Dialing for water

Kelvin Lugaka is a young Kenyan water specialist at Umande Trust who leads the M-Maji project. He implements the technology and gets people to use it. Lugaka grew up in Kibera and is proud of his childhood home that he calls a human settlement, not a slum. His parents and siblings still live here, and he knows all the water vendors in the five villages where the technology is being piloted.

Walking through Kibera, Lugaka shows how M-Maji works on a very basic Nokia mobile phone – the kind that costs the equivalent of $15 on the second-hand market. The technology was developed by a local team of Kenyans working for Wezatele, a Nairobi-based startup located at the iHub technology incubator.

Lugaka dials *778# onto the phone's large buttons. A few seconds later, a SMS message pops up on the phone's small screen prompting him to press "1" for water, "2" to sell water or "3" to file a complaint. He presses "1" and a list of villages appear that have water available that day. Next to each landmark is the cost of water that day.

Because there are no street signs in Kibera, the M-Maji team had to use popular landmarks – schools, health clinics and churches – to identify water vendors locations.

"M-Maji is going to have the coordinates for water vendors, which will allow people to find out information about water and the cost of water today, so people can move to a different water vendor (if the price is too high)," says Lugaka.

Each morning the registered water vendors are responsible for entering the price of water at their kiosks into the M-Maji system. Lagaka currently has 45 water vendors registered in the system but would like that number to grow to 100.

A unique partnership

Josiah Omotto is one of Umande Trust's original founders. Raised in Kibera, Omotto has devoted his work to improving water and sanitation conditions in the community.

He has a booming voice and commanding presence. When he speaks, everyone in the room listens.

"Umande Trust implies that you wake up in the morning with a new perspective on the world," Omotto says. "We work on projects that do not recycle the ideas or biases of yesterday."

The power of technology to advance change has always been part of Omotto's vision for development in Kibera and before working with Stanford he claims there were no other mobile phone-based projects here.

"Access to information is power and technology represents the future potential to transfer and share information," he says.

Over a lunch of rice, vegetables and bits of meat, Omotto talks about the unique partnership with Stanford. It’s unusual to see student researchers in the field translating knowledge into practice and impact, he says. Other researchers have showed up at Umande Trust to collect data for their surveys. But they rarely stay long enough for lunch or a walk through Kibera.

Before the course starts, students spend over a week in Kenya meeting with local NGO partners, conducting needs assessments with the community and developing the ideas that will turn into their design projects.

Some of the prototypes created have used mobile phones for reproductive health counseling, to coordinate a system of community foot patrols, provide legal advice, report violent crime, and incentivize savings, among others. With the ease of a mobile device, they attempt to break the information divide that exists in Nairobi's poorest communities to connect users directly to medical, health and legal professionals.

Not all the projects succeed. But M-Maji seems to be defying the odds.

Leveling the playing field

A female water vendor hopes the M-Maji service will increase business at her kiosk. Photo Credit: Sarina Beges

Standing outside in the hot afternoon sun as water trickled from the tap into the muddy street, one of Kibera's few female water vendors enthusiastically endorsed the M-Maji service. She’s optimistic that the service would drive more customers to her smaller kiosk that struggles to compete with the larger vendors in Kibera.

At her station, a teenage girl rinses her clothes in bright red plastic basins of soapy water as young children run through the narrow streets filling small tin cups. As they drink, dogs fight over scraps of garbage.

"M-Maji allows the poorer water vendor to enter the marketplace," Omotto says. "The larger water vendors are well known, they control the water supply and are connected to big political players and the government. The moment you make this information open you liberalize the system."

M-Maji's co-founder agrees.

"The system will put downward pressure on the water prices so if you are selling water for five shillings when it is only worth two shillings, then someone else will sell it for four and people will go there," Jeon says.

In discussing the politics of water, Omotto says water is one of the few areas the Kenyan government has been making an effort to improve in Kibera.

"The government does not invest in informal settlements," he says. "Resources are typically channeled outside the city into rural areas or spent on defense and the police."

Omotto shrugs his shoulders when asked why water policy has improved in Kibera and suggests that the new Kenyan constitution – which contains provisions for water rights – might be the answer. Or he just chalks it up to politics, suggesting that it may have to do with the political ambitions of the current water minister. Not surprising in a country where resource allocation and politics go hand-in-hand.

Scaling the service

As the project grows, water quality testing is going to be an important component. M-Maji is planning to do periodic tests on the water quality and would eventually like to employ infographics technology to visually plot the sources of contaminated water for residents. Jeon is hoping to work with the U.S. Centers for Disease Control and Prevention's office in Kibera on water quality testing.

While M-Maji is gearing up for a full launch of the service this year, they expressed concern about the sustainability of the project. For the pilot they received small grants through the Freeman Spogli Institute's Global Underdevelopment Action Fund and the Center for Innovation in Global Health. But it is uncertain where the funding will come from going forward.

M-Maji does not charge people to use the service, which is equivalent to the cost of sending a text message, but will be unable to subsidize the service indefinitely.

"The cost of sending a message through M-Maji is the cost of one vegetable or liter of water," Omotto says, underscoring the trade-offs that will force the M-Maji team to work hard to prove the utility of the service to the community and vendors.

Umande Trust has already received 400 calls from community members interested in the service and believes M-Maji will have traction on the ground once it is fully launched. Lugaka has been busy working with the local radio station in Kibera to develop advertisements for M-Maji as part of a larger community outreach strategy.

The problem of water availability and quality are not unique to Kibera. If the project takes off it has the potential to scale to other human settlements across Africa and the world.

"If the technology works perfectly then Kibera is just the start,” Jeon says.

Outside of China, the world now has more food insecure and nutrient deficient people than it had a decade ago, and the prevalence of obesity-related diabetes, high blood pressure and cardio-vascular diseases is increasing at very rapid rates. Expanded food production has done little to address the fact that between one-third and one-half of all deaths in children under five in developing countries are still related to malnutrition.

“With only three years away from the Millennium Development Goals deadline, this is a terrible track record,” said food and nutrition policy expert Per Pinstrup-Andersen at FSE's Global Food Policy and Food Security Symposium Series last week.  

Pinstrup-Andersen, the only economist to win the World Food Prize (the ultimate award in the food security field), has dedicated his career to understanding the linkages between food, nutrition, and agriculture. What is driving persistent food insecurity and malnutrition in a food abundant world?

Poor food supply management is part of the problem. According to the United Nations Food and Agricultural Organization (FAO), 20-30% of food produced globally is lost every year. That’s enough to feed an additional 3-3.5 billion people.

Jatropha in Africa. Photo credit: Ton Rulkens/flickr.

Biofuels production, such as jatropha in Africa, now competes with food for land, and climate change is already negatively impacting crop yields in regions straddling the equator—with major implications for food supply.

For low-income consumers in both the U.S. and developing countries increasing and more volatile food prices, such as those seen in 2007, are also driving food insecurity. Poor consumers respond by purchasing cheaper, less nutrient food, and less of it.

Nutritional value chain

Consensus is developing—at least rhetorically—among national policymakers and international organizations that investments in agricultural development must be accelerated. Members of the G8 and G20 have committed $20 billion in international economic support for such investments and some developing countries such as Ethiopia and Ghana are planning large new investments.

While most of these recent initiatives focus on expanded food supplies, there is an increasing understanding that merely making more food available will not assure better food security, nutrition, and health at the household and individual levels.

“It matters for health and nutrition how increasing food supplies are brought about and of what it consists,” said Pinstrup-Andersen. “We need to turn the food supply chain into a nutritional value chain.”

Diet diversity is incredibly important for good nutrition. Agricultural researchers and food production companies need to look at a number of different commodities, not just the major food staples, said Pinstrup-Andersen.

“The Green Revolution successfully increased the production of corn, rice, and wheat, increasing incomes for farmers, and lowering prices for consumers, but now it is time to invest in fruits, vegetables and biofortification to deal with micronutrient deficiency,” said Pintrup-Andersen.

Biofortification, the breeding of crops to increase their nutritional value, offers tremendous opportunity for dealing with malnutrition in the developing world, but is not widely available.

This is particularly important for areas in sub-Saharan Africa where between one and three and one and four people are short in calories, protein, and micronutrients. Obesity is actually going up in these countries with the introduction of cheap, processed, energy-dense foods (those high in sugar and fat) contributing to the diabetes epidemic.

Pathways to better health

Women hauling water to their gardens in Benin.

The path to better health and nutrition must look beyond the availability of food at affordable prices, clean water, and good sanitation, and consider behavioral factors such as time constraints for women in low-income households.

“Field studies have shown time and time again that one of the main factors preventing women from providing themselves and their families with good nutrition is time,” explained Pinstrup-Andersen.

He told the story of a woman in Bolivia too burdened with farm and household responsibilities to take the time to breastfeed her six-month old daughter. Enhancing productivity in activities traditionally undertaken by women could be a key intervention to improving good health and nutrition at the household level.

Access is another issue. A household may be considered food secure, in that sufficient food may be available, but food may not be equally allocated in the household.

“If we focus on the most limiting constraint we can be successful,” said Pinstrup-Anderen. “But we must tailor our response to each case.”

For sub-Saharan Africa, this includes investments in rural infrastructure, roads, irrigation systems, micronutrient fertilizer, climate adaptation strategies, and other barriers holding back small farmers.

Fortunately, there has been a renewed attention to the importance of guiding food system activities towards improved health and nutrition. The Global Agriculture and Food Security Program (GAFSP), which facilitates the distribution of some of the G8 and G20 $20 billion commitments, prescribes that country proposals for funding of agricultural development projects must show a clear pathway from the proposed agricultural change to human nutrition.

“But it’s not going to be easy to implement good policies,” warned Pinstrup-Andersen. “There are few incentives in government for multidisciplinary problem solving. The economy is set up around silos and people are loyal to their silos. Agricultural and health sectors are largely disconnected in their priorities, policy, and analysis."

Incentives must change to encourage working across ministries and disciplines to identify the most important health and nutrition-related drivers of food systems, impact pathways, and policy and program interventions to find win-wins for positive health and nutrition.

Rising temperatures, an uncertain water supply and more abundant pests threaten California's multi-billion-dollar crop industry. FSE agricultural scientist David Lobell weighs in on climate impacts on California's cherry crop--the canary in the climate coal mine--as part of a half-hour documentary on "Heat and Harvest", a co-production of KQED and the Center for Investigative Reporting,

Pamela Matson, Dean of the School of Earth Sciences and FSE researcher, discusses agricultural research in the Yaqui Valley, Mexico and how it relates to the Green Revolution with Stanford's Generation Anthropocene. She also reflects upon the politics of sustainable agriculture and how we might go about feeding the 9 billion people we expect in the coming decades.