WHO – UAB Institute for Human Rights Blog

The Eradication of Malaria in Egypt: A Triumph for Public Health and Human Rights

When thinking about malaria, we tend to forget its impact across the world. Especially living in the global north, my experience with malaria has been restricted to my coursework; however, the reality of the disease is that it exists and poses a prominent issue in many countries across the world. The illness, spread by a mosquito vector, had over 247 million cases in 2021; this spanned across many regions worldwide, primarily impacting Africa.

In recent years, the WHO (World Health Organization) has worked in many different countries to eradicate malaria and has successfully done so with their WHO Guidelines for Malaria. An example of these guidelines being successful is Algeria, which reported its last case in 2013. However, a recent accomplishment in the world of malaria has been noted, which is the eradication of the disease in Egypt. For decades, Egypt had struggled with the disease and the associated outcomes.

Image 1: Receipt of malaria-free certification in WHO Eastern Mediterranean Region.Source: WHO — Image 1: Receipt of malaria-free certification in WHO Eastern Mediterranean Region. Source: WHO

Malaria’s History in Egypt

The nature of Egypt had made it susceptible to the fruition of the illness. Historically, the disease was tested around the Nile Delta and Upper Egypt, tracing back to 4000 B.C.E. As most of the population was concentrated in these areas, it led to the development of disease impacting millions of individuals. In recent history, the illness has contributed to the fragility of the country, ranging from increased economic losses, inflated healthcare costs, and decreased labor productivity.

The first ever effort to control malaria can be dated to 1950, with the introduction of dichloro-diphenyl-trichloroethane (DDT). This initial intervention was an insecticide that was used to help not only reduce the mosquito population but also address the development of typhus and other insect-borne diseases. However, this intervention resulted in some resistance amongst the community and additional environmental concerns; as of 2001, the intervention was observed as a possible human carcinogen and has since been banned in Egyptian agriculture.

In 1969, the creation of the Aswan Dam posed a new risk for the development of disease, all of which resulted in the need for new interventions. With additional adjustments to the approach against malaria, in the 1980s, the WHO helped push towards the eradication of malaria in Egypt with their eradication program. This program included regions like Africa, the Americas, Asia-Pacific, and the Middle East and Eurasia. This resulted in outcomes such as reducing the number of cases by 300,000 between 1980 and 2010. Though these outcomes are significant, those with limited access to healthcare were still disadvantaged in the global conversation.

Image 2: Doctors in Egypt are conducting malaria tests on elderly patients in rural Egypt.Source: WHO — Image 2: Doctors in Egypt are conducting malaria tests on elderly patients in rural Egypt. Source: WHO

The New Approach to Malaria

Building upon previous interventions, additional interventions have been explored in the past few decades; these have contributed meaningfully to the eradication of malaria in the country. Before mobilizing interventions, it is important to educate communities about what malaria is and develop trust in proposed interventions. The Egyptian government, in collaboration with different NGOs (Non-Governmental Organizations), launched different campaigns that reached communities all across the country; these talked about prevention, symptoms, and where people can find diagnostic centers. These were taught in schools, local community centers, and other locations to ensure that populations were able to access the information needed to become a part of the solution. This resulted in an 80% increase in malaria case reporting in disproportionately impacted areas by 2020.

These education opportunities are coupled with healthcare access and monitoring. By improving the healthcare infrastructure, treatment facilities were able to strengthen their interventions for those impacted by malaria. However, with recent inflation and economic instability in the country, with the support of international supporters, these interventions became even more accessible by being low-cost or even free. With the additional investment into data collection and monitoring systems, the Egyptian Ministry of Health was able to monitor trends in malaria incidence and collaborate with healthcare providers to mobilize and target interventions for those who need them most. With the compounded efforts of treating and monitoring malaria, strides were made to help understand the spread of malaria in the country.

Beyond education and monitoring, it is valuable to identify interventions that would be accessible to the population. These interventions must be easily understood to ensure they are efficacious. Vector control is noted to be central to Egypt’s strategy. Leveraging the use of insecticide-treated bed nets was the most prominent intervention; by 2019, 3 million of these nets had been distributed to reduce the incidence of malaria, especially in high-risk areas. This, coupled with indoor spraying, helped reduce malaria cases by 90% in over 2 decades.

Malaria Eradication is a Victory for Human Rights

As outlined in the International Covenant on Economic, Social, and Cultural Rights, the right to health is fundamental to human existence. By working to eradicate malaria in the country, Egypt has made strides to fulfill this right for its citizens of all socioeconomic classes.

Egypt’s victory brings hope to the fight against malaria; not only can public health interventions align with human rights, but they can create a sustainable model for health equity. Many countries in the global south are in a place that Egypt was in not too long ago; as global communities begin to face the amplification of health issues, Egypt’s framework and history of eradication can be seen as a success and applied to other countries.

Now that malaria is off the docket of issues Egypt faces, it is not time to focus on addressing other inequities the country is facing. As health equity is improved in the country, issues such as mental health, maternal and child health, and non-communicable diseases can be addressed with the utmost efficiency, helping improve outcomes in the country.

The Forced Virginity Testing of Women in Afghanistan

A woman with a white headscarf holding a poster that says "Afghanistan" — A demonstrator attends a rally by Afghanistan’s Hazara minority for community’s rights, outside the Brussels Conference on Afghanistan, Belgium, October 5, 2016. REUTERS/Francois Lenoir

Afghanistan has had a long history of being a patriarchal society. Cultural customs that have suppressed the rights of women have been popularized and justified on the basis of morality. With these customs largely targeting women behavior, Afghani women are faced daily with gender inequality. One of the most brutal threats is the risk of a barbaric practice called virginity testing. Many women at some point are forced to go through the painful examination. The procedure involves a medical professional forcing two fingers inside of the women’s vagina, often forced and against her wishes, in order to determine if the women’s hymen is still intact. One might ask why anyone would force women to endure an assault on their most private areas. The terrible answer is that virginity testing is done to ensure that the woman has not had sexual relations with any man.

In Afghanistan and other countries such as India that widely practice virginity testing, a woman’s virginity is highly coveted. It is a symbol of modesty and purity. The societal expectation is that it is never okay for women to have any sexual experiences outside of marriage. Women’s actions are extremely regulated and controlled by the men of the family. Having a virginity test is often required for many basic rights such as the option to go to school, obtain a job, or get married. Faced with limited choices, many women see no other way than to submit to the test out of fear of the repercussions.

The punishments for defying these unfair gender inequalities is severe. In fact, an Afghan woman found to have had sex before marriage is subject to prosecution and imprisonment under what is known as a ‘moral crime.’ The societal penalties extend much further than jail time. Girls are thought to have had premarital sex are publicly humiliated after word spreads of their failed virginity test. They are often ostracized by their families for bringing shame upon them. Some families will go so far as to commit honor killings which is the murder of a woman by her male family members for bringing shame upon the family. For a society to criminalize female sexuality and even threaten death is an egregious violation of female human rights.

The United Nations, World Health Organization, United Nations Women, and the United Nations Human Rights Council have all called for a global ban on the practice. However, this will not do these women much good. These organizations have no ability to enforce their will and can only hope to draw attention to the issue. There are many reasons to campaign for an end to virginity testing; for the purpose of this blog, I will highlight three. The first and most obvious reason is the disregard for a women’s right to say no. A woman should be allowed to deny any medical procedure that she does not wish to have for any reason. Any vaginal procedure done without consent is sexual and physical assault.

The second reason to outlaw this practice is that it continues unfair gender inequality and enforces unhealthy stereotypes. Why are only women required to undergo testing for sexual ‘purity’? Why is it that it is considered immoral for women to be sexually active and not men? This problem extends far beyond Afghanistan and is a worldwide issue. There is a clear gender bias against women having sex. On the other hand, men are often complimented for their sexual prowess. If gender equality is to be realized, then there needs to be a cultural cleansing of the many double standards placed on women.

Lastly, the most damning reason why vaginal testing shouldn’t be used is that it doesn’t work. The World Health Organization has found that there is no scientific basis for the claim that a torn hymen is evidence that a woman has had sexual intercourse. In fact, they have found that there are many nonsexual ways that the hymen can be damaged. For instance, the use of a tampon or being physically active in sports like gymnastics can cause the hymen to break. The sole reason for subjecting women to this painful test is to confirm that they are virgins. If a virginity test can’t prove whatsoever that they are or aren’t virgins then there is no logical explanation to continue this practice.

Afghani girls — A female engagement team from Combined Task Force Lightning, met with women and girls to focus on health education at Baqi Tanah, Spin Boldak District, Kandahar province, Afghanistan, June 20. Source: DVIDSHUB, Creative Commons.

Currently, there are several thousand women, many as young as 13, imprisoned for failing one of these inconclusive virginity tests. On top of being imprisoned with faulty evidence for an unjust crime, these girls are subjected to terrible prison conditions. Farhad Javid is in charge of Afghanistan’s division of Marie Stopes International, an organization focused on protecting women’s sexual rights. Javid recently visited the Mazar-i-Sharif prison where many women convicted of ‘moral’ crimes are held. He found that these women face severe overcrowding, lack of access to proper healthcare, and constant, daily sexual assault. Women falsely convicted of having sex have reported being frequently forced to have sex with prison guards and staff. Due to the lack of reliable evidence of these women’s alleged crimes and the inhumane treatment these girls are facing in prison, Javid is campaigning for the immediate release of all women being imprisoned for ‘moral’ crimes.

Unfortunately, even after being released from prison these women will have lasting problems. For the rest of their lives, they will have to deal with the trauma and memories of the forced virginity test as well as the sexual abuse they underwent in prison. On top of this, they will likely have a hard time finding stability. Despite being falsely convicted with invalid evidence, their reputations have been permanently and irreparably stained. For most of these girls, their families have already disowned them. They have no intention of taking back a daughter who they believe to have committed ‘moral’ atrocities that have brought shame upon their family. Also, these girls have been imprisoned at young ages and have not completed an education or have been married. With no family, husband, or education to support themselves with and nowhere to go these women’s future outlooks are grim. There aren’t many resources available to women in Afghanistan without a family or support system. The majority will end up at overcrowded and underfunded women’s shelters. Without proper protection, they are in constant threat of violence or rape. Their lives will be constantly haunted by this ordeal like being branded by a scarlet letter.

It is astounding how easy it is for these women’s entire lives to be turned upside down. Simply walking down the street with a boy or getting a ride home from a boy is enough to get reported to the police by family members or neighbors. The authorities waste no time ordering a virginity test. Despite the girl having done nothing wrong, there is a real and terrifying chance that she will fail the unreliable test and be imprisoned. It is obvious that much change is needed to prevent this same tragedy from happening to more innocent young girls.

The solution to this problem lies at the local level. If the people are well-informed about the test’s ineffectiveness, then they will stop requesting the examination take place. A massive public relations campaign could be used to accomplish this task. Local governments need to partner with the many nonprofit organizations committed to helping improve the rights of women. By doing so these local governments will have the necessary funding and manpower to launch a public relations campaign with individuals well qualified to teach the public about the ineffectiveness of virginity testing. Another solution is proposed by Javid and the Marie Stopes Afghanistan. Recently Marie Stopes helped the Afghanistan government to create a new policy that discourages doctors from pursuing these tests. The policy states that virginity tests have no scientific credibility and should not be administered by health care professionals for the purpose of determining if a girl is a virgin. Marie Stopes is sending out doctors to both train hospital staff and ensure the new policy is carried out and taken seriously at each hospital in Afghanistan. This initiative aims to tackle the problem by reducing the credibility of virginity testing. If no licensed doctors are willing to perform the procedure due to official public policy, then the hope is that law enforcement will stop requesting and in some cases pressuring doctors to conduct virginity testing on suspected girls. Law enforcement will be forced to subject girls to exams by unlicensed non-professionals if they wish to continue the use of virginity testing. This will lower the integrity of their claims of proving the state of a girl’s virginity and will surely aid in gaining local support to end the barbaric practice.

If the work to accomplish this solution is continued, then real progress will be made. If the government and culture of Afghanistan can be open to a small amount of change then thousands of other girls can be saved from such terrible experiences. While there are many other unfair gender practices common in this region, this campaign will be a large step towards the path to gender equality. With continued public relations campaigns and pressure for governmental action, an Afghan society that treats women fairly and empowers them to be in control of their lives will be enacted.

The ‘Invisible’ Killer

Simply because you cannot see air pollution, does not mean air pollution does not exists. Often, pressing issues such as air pollution and other environmental problems such as soil contamination are dismissed because the effects of pollution are not always tangible until extreme environmental disasters occur. On December 5, 1952 the residents of London, England suffered five days of devastating toxic clouds known as the Great Smog. Various factors contributed to the creation of the smog, daunting the city of London. First, London, England was a manufacturing city utilizing coal for industrial purposes. Second, residents used coal in household heaters to brace against the December cold. Exacerbated by acrid black smoke from millions of chimneys and manufacturing plants, “a high-pressure weather system had stalled over southern England and caused a temperature inversion, in which a layer of warm air high above the surface trapped the stagnant, cold air at ground level. The temperature inversion prevented London’s sulfurous coal smoke from rising, and with nary a breeze to be found, there was no wind to disperse the soot-laden smog.”

Trafalgar Square. Source: Leonard Bentley, Creative Commons

The consequences of this event were immense, as an estimated 4,000 people died due to health conditions, such as bronchitis and pneumonia which increased more than seven-fold in the immediate aftermath of this environmental disaster.

Outdoor Air Pollution
The Great Smog is one consequence of extreme environmental pollution. In the subsequent 60 years+ since the Great Smog, countries over the world such as China and India continue to bare the effects of both outdoor and indoor air pollution on the health communities. The effects of air pollution on the health of populations is a human rights issue; it essentially affects one’s right to health and life. Numerous epidemiological studies formally recognize the negative effects of air pollution on human health. In 2013, air pollution was officially classified as a cause of lung cancer by World Health Organization’s (WHO) International Agency for Research on Cancer (IARC). WHO finds “the combined effects of ambient (outdoor) and household air pollution cause about 6.5 million premature deaths every year, largely as a result of increased mortality from stroke, heart disease, chronic obstructive pulmonary disease, lung cancer and acute respiratory infections.” And more specifically, the WHO states ambient air pollution globally causes:

1) 25% of all deaths and diseases from lung cancer,

2) 17% of all deaths and diseases from acute lower respiratory infection,

3) 16% of all deaths from stroke internationally,

4) 15% of all deaths and disease from ischemic heart disease, and

5) 8% of all deaths and disease from chronic obstructive pulmonary disease.

Human activity is a driving force behind air pollution. Human activities contributing to air pollution include industrial facilities such as manufacturing companies, power generation such as coal plants, fuel combustion from motor vehicles, and waste burning.

The morbidity and mortality contact to air pollution causes globally emphasizes how our personal contributions to air pollution not only harms us individually but also affects everybody else on this earth. Air pollution wasn’t caused by one entity, but rather accumulate to dangerous levels due to the actions of people from every single part of the world. Optimistically, there are plentiful habits people can change in their lives to promote cleaner air. On a community level, individuals can participate in carpooling to places such as school or work to reduce toxic emission from transportation, eliminating waste generation by not using plastic materials and recycling to prevent potential waste burning, and even supporting local community groups that address pollution concerns by volunteering. Education is also another tool that is needed to decrease levels of air pollution. Communities may not be aware of the consequences of exposure to air pollution. Educating communities about methods to decrease the production of pollution empowers people to improve and protect the health of their communities. As people, we will need to continue to work together to combat air pollution, educate communities, and implement sustainable life style changes.

Activists gather to demand clean air as Edinburgh Air Pollution Zone to be expanded. Source: Friends of the Earth Scotland, Creative Commons.

Indoor Air Pollution
Even though air pollution impacts the entire global community, lower income communities are at greater risk of exposure to indoor air pollution (IAP). The World Health Organization states “3 billion people cook and heat their homes using solid fuels (i.e. wood, charcoal, coal, dung, crop wastes) on open fires or traditional stoves. Such inefficient cooking and heating practices produce high levels of household (indoor) air pollution which includes a range of health damaging pollutants such as fine particles and carbon monoxide.” As a result, 4.3 million deaths may be accredited to the negative health impacts of household air pollution annually.

Exposure to air pollution is inequitable. Rural and lower socioeconomic communities do not have access to sufficient stoves, energy and indoor ventilation, creating disproportionally exposure to household indoor and potential negative health effects. WHO finds approximately 90% of the 3 million premature deaths due to outdoor air pollution transpired in low- and middle-income countries. Furthermore, the highest burden of outdoor air pollution occurred in the WHO Western Pacific and South-East Asia regions. Additionally, in 2000 60% of IAP induced deaths affected women. Women are at greater risk for exposure to IAP due to being responsible for cooking, and household duties. Finally, young and newborn children are a vulnerable population and at greater risk for exposure to household pollution due to being with their mothers while she cooks and preforms other daily activities.

Disparities in the USA
Air pollution disproportionally effects lower income countries and populations. However, environmental injustice is not a foreign concept for low income minority communities all over the United States of America regardless of policies such as the Clean Air Act. Marginalized Americans continue to bear the consequences of environmental racism – “the racial discrimination in the enactment or enforcement of any policy, practice, or regulation that negatively affects the environment of low-income and/or racially homogeneous communities at a disparate rate than affluent communities.” A nationwide environmental research study highlights black, Hispanic and low income students are at greater risk to exposure to harmful toxins in school. The research found:

1) African American students make up 16% of US public school students, yet, more than 25% of those students attend schools worst affected by air pollution,

2) white school children account for 52% of all US public school attendees, however, only 28% of those white students attend schools worst affected by air pollution,

3) schools with large student of color population are located near busy roads, factories and other major sources of air pollution, and

4) five of the ten worst polluted school counties contain a non-white student populations greater than 20%.

This is just one example of lower income communities experience inequitable consequences of air pollution in the US. Other prominent examples of the negative health impacts of air pollution on minority and low income communities include Cancer Alley in Louisiana and the Anniston Community Health Survey. Epidemiological studies strongly support the relationship between health and air pollution.

Ultimately, the health and overall quality of life of communities should not be jeopardized based on socioeconomic status, gender, age and race. GASP, a local Birmingham non-profit, is an important stakeholder in keeping our Birmingham communities air clean. GASP is a local advocate for clean air by:

1) monitoring, reporting and documenting air quality issues,

2) raising awareness of the health effects of air pollution on childhood health outcomes,

3) empowering and better educating local community member on advocacy skills for clean air, and

4) promoting environmental justice through policy change. More information such as contact information is available on their website. Protecting and promoting our environmental health is a community effort.

Organizations like GASP are important in ensuring all American citizens have equal rights to health and life without discrimination. As a community we need to continue to supporting community advocacy and education initiatives about air pollution, as they are major stakeholders in the success of environmental improvement. A healthy and clean environment is possible if we continue to work together.