Rwanda was one of the poorest countries in the world in 1994, after a genocide claimed more than 500,000 lives and left the country with little or no access to medical services. In the late 1990s, it began to rebuild its infrastructure. Now, according to the Rwandan Ministry of Health , the country provides health care and insurance to more than 90 percent of its population, inspiring medical leaders from around the globe to visit the African country to study its transformation.

Now, the Harvard Medical School is working with the Rwandan Ministry of Health to teach a course called Global Health Delivery in the village of Rwinkwavu twice a year.

“Rwanda is honestly starting to change the face of global health,” said Dr. Paul Farmer, one of the founders of Partners in Health , a nongovernmental organization that works in Rwanda and other poor countries. He is also the chairman of Harvard’s Department of Global Health and Social Medicine and one of the faculty members for its course in Africa.

In February, 30 African medical leaders met with Harvard faculty at the training and research center in Rwinkwavu to discuss the challenges of delivering health services in resource-poor settings. Six of these students were trained to become faculty members who will teach future classes, with the next sessions scheduled for July.

During the weeklong course, students and professors discussed case studies and conducted field visits throughout Rwanda. Because all the students are currently health workers — most are employees of the Rwandan Health Ministry — they are able to immediately apply what they learned in the Harvard course to their daily work.

Initially, the course was held only on Harvard’s campus, where students would discuss case studies on the difficulties of delivering medical services internationally.

But the course changed in February. A world away from Cambridge, Massachusetts, health professionals in Rwinkwavu discuss the same case studies. They also participate in live cases, in which students and faculty members interview doctors, nurses or other health workers, like the head of an organization working to deliver AIDS medications to the poor in Rwanda, to ask them about the challenges of their work. Visits to Rwandan clinics and hospitals allow students to see health care in action, and give them the opportunity to collaborate with other professionals to discuss solutions.

“To be a good global health provider, it’s good for students to see what others have done,” Dr. Agnes Binagwaho, who is both the Rwandan health minister and a Harvard faculty member, said by telephone.

Seeing potential for the course outside of Massachusetts, Dr. Binagwaho worked with Partners in Health to bring the Harvard curriculum to her home country.

“We hope to have students come from around the world and learn from them as well, and also have the students learning from each other, because they are all coming from countries where there are things ongoing,” she said.

There is now also a new Harvard degree, a Masters in Medical Sciences and Global Health Delivery, which will begin this autumn. Plans to offer a similar degree in Rwanda are under way.

“Above all, you need people who actually do the delivery to tackle the problems,” Dr. Farmer said. He stressed the importance of working not only in Africa, but also with African health care leaders. “Not everyone has the privilege to make it to Harvard — and we needed to reach out,” he added.

The Harvard course is one of the first that focuses exclusively on the challenges of delivering health care. It encourages students to think about how politics, economics and other social factors affect health.

“I don’t know many other groups that are looking at health care delivery as a field of study and bringing that to collaboration with African ministries of health,” said Dr. Joseph Rhatigan, the director of the Global Health Equity residency program at the Brigham and Women’s Hospital, a teaching hospital affiliated with Harvard in Boston.

Partnerships between medical schools and the developing world are increasingly common, but the majority focus on practicing medicine as opposed to delivering care and understanding the effect of social factors, he said.

Dr. Corine Karema, director of the programs for malaria and neglected tropical diseases at the Rwanda Biomedical Center and one of the students in the Harvard course who trained to become a faculty member, said the course made her change the way she looked at medical treatment.

“I’ve been working for a long time in public health, and we used to decide on intervention and strategies if they were cost effective without looking at how the strategy will best affect the patient,” she said.

Mobile technology is changing the landscape of health care delivery across the developing world by giving people who live in rural villages the ability to connect with doctors, nurses and other health care workers in major cities.

“Now, a phone call can compress the time that it would have taken before to come to that decision point and get the woman care more often and quickly,” said Dr. Alain Labrique, a professor of International Health and Epidemiology at Johns Hopkins University, in Baltimore.

More than 60 faculty members and 120 students are part of the Johns Hopkins Global mHealth Initiative, which has 51 projects exploring the use of mobile technology in health.

Its work received such a positive response that in March 2013, the Johns Hopkins Bloomberg School of Public Health will begin two courses on incorporating mobile technologies into global health fieldwork.

“The students coming into global health today are challenged with the need to think of the potential appropriate use of these technologies in the resource-limited areas where we work,” said Dr. Labrique. “There’s a lot of excitement among faculty, but there’s 10 times as much excitement coming from students.”

“What mobile technologies are doing is changing the way that we see global health in terms of our ability to impact populations, to collect data in real time, to develop real strategies to impact public health that we hadn’t thought of before,” he added.

Dr. Larry Chang, a Johns Hopkins researcher who studied H.I.V./AIDS and the use of technology in Uganda, said that “over the past decade of working in Africa you really started seeing this amazing growth in the use of mobile phones and it seemed obvious to use it for global health.”

While mobile technology is one of the quickest ways to deliver health care to those who would otherwise have little to no access, there are challenges in making the technology effective.

“There hasn’t been a lot of rigorous evaluation of their impact,” said Dr. Chang. “We need to study and make sure that these devices are doing what people say they are doing and that they are really helping people.”

Students face challenges beyond simply figuring out the most efficient way to use mobile technologies to deliver health care.

When phones can bring care to 50,000 patients as opposed to 50, it is important that other resources, like health care professionals and medical services, also be increased to support the larger workload, Dr. Labrique said.

He said that “mHealth has the potential to be integrated into the way we teach.”

“We have to be able to demonstrate how much impact on a mortality or health outcome they have before they actually get recognized by global bodies like W.H.O. and the mainstream health system,” Dr. Labrique added.

Find the original article here: http://www.nytimes.com/2012/05/14/world/africa/exploring-the-role-of-mobile-technology-as-a-health-care-helper.html?_r=1&ref=africa

By Katie Koch

Harvard Staff Writer

Thursday, May 3, 2012

Pascal Guyot/Agence France-Presse — Getty Images

Charles Taylor, seen in 1990 on the outskirts of Monrovia, led the rebel National Patriotic Front of Liberia before assuming the country’s presidency.

The ruling, announced by Presiding Judge Richard Lussick of Samoa, said Mr. Taylor was guilty of involvement in crimes against humanity and war crimes including murder, rape, slavery and the use of child soldiers. The court, however, said the prosecution failed to prove that Mr. Taylor had direct command responsibility for the atrocities in the indictment.

Mr. Taylor, who has maintained his innocence, will be sentenced in the coming weeks. There is no death penalty in international criminal law and any jail term would be served in a British prison.

The conflict in Sierra Leone became notorious because of its gruesome tactics, including the calculated mutilation of thousands of civilians, the widespread use of drugged child soldiers and the mining of diamonds to pay for guns and ammunition. A new, sinister rebel vocabulary pointed to the horrors: applying “a smile” meant cutting off the upper and lower lips of a victim, giving “long sleeves” meant hacking off the hands and giving “short sleeves” meant cutting the arm above the elbow.

The trial has brought “a sense of relief,” said Ibrahim Tommy, who leads the Center for Accountability and Rule of Law, a rights group in Freetown, the capital of Sierra Leone, “but I’m not sure it will bring closure to the victims.” Even so, Mr. Tommy said, the trial was “a genuine effort to ensure accountability for the crimes in Sierra Leone.”

In Liberia, Mr. Taylor’s supporters have maintained that he is the victim of an American witch hunt, but others lament that his former associates have prospered and play a role in the new government.

The tribunal, called Special Court for Sierra Leone, which has its main seat in Freetown, has already sentenced eight other leading members from different forces and rebel groups for crimes in Sierra Leone.

Largely an initiative of the United States and Britain, the court was established in 2002 in partnership between the United Nations and Sierra Leone to prosecute those responsible for atrocities in a conflict that led almost half the population to flee and left an estimated 50,000 dead.

The fighting for control over one of the world’s poorest regions also involved Liberia, where many more died, and threatened to spill over into neighboring Guinea and Ivory Coast. But only crimes in Sierra Leone between 1996 and 2002 are within the court’s mandate.

Mr. Taylor is the special court’s last defendant. His trial was moved here, to The Hague, for fear of causing unrest in the region where he still has followers.

During the lengthy trial, which began in 2006, judges from Ireland, Samoa and Uganda heard testimony from 115 witnesses, many from the region who had never traveled before.

Before the formally robed court officers, they spoke of slave labor in captured diamond mines, episodes of cannibalism, rape, severed heads displayed on stakes to terrorize people and captured villagers lining up, waiting to have their limbs hacked off.

There were many chilling moments, as witnesses described the barbarism of the rebels, gesticulating with the stumps of amputated limbs swaddled in bandages.

Mustapha Mansary, a villager, was twice asked by the defense lawyer if he could read and write English, until he held up his two bandaged stumps.

“I have no hands to write anything,” Mr. Mansary replied.

But prosecutors struggled with a legal puzzle of how to link them to Mr. Taylor. There was no paper trail showing orders. There was no record of Mr. Taylor ever going to Sierra Leone. He was not at the scene of the crimes, and they were not committed by the army of Liberia, which was under his command.

To build their case, prosecutors used radio and telephone intercepts and brought in radio operators who had connected Mr. Taylor’s mansion in Monrovia to the rebels in the bush in Sierra Leone.

People close to Mr. Taylor, his head of security, bodyguards and other associates, some of whom were relocated abroad as protected witnesses, testified about arms and ammunition shipments for the rebels and to seeing raw diamonds arriving as payment.

Bank records were displayed in court, showing how tax payments and other government income moved into Mr. Taylor’s accounts, ostensibly to pay for the war effort, or for himself.

Defense lawyers dismissed much of the evidence as hearsay. And they repeatedly said the trial was a political exercise by Western countries who wanted to keep Mr. Taylor out of West Africa.

Much of the court’s budget has been paid for by voluntary contributions from the United States, Britain, Canada and The Netherlands.

To support their argument, the defense presented as evidence two secret diplomatic cables from 2009, part of the cache revealed by WikiLeaks, in which American diplomats wrote about Mr. Taylor.

One, dated March 2009, quoted the American ambassador to Liberia as saying that “the best we can do for Liberia is to see that Charles Taylor is put away for a long time.” The most important defense witness was Mr. Taylor himself. Eloquent and respectful of the court, he managed to remain on the witness stand for more than 50 days, giving his version of his life and his role as a peacemaker, without the judges cutting off his many off-topic digressions.

He told the court that had he been trained in Libya, once received money from Muammar el-Qaddafi for “medical expenses.” While he was in a Massachusetts jail awaiting extradition on charges of embezzling $900,000 of Liberian government funds, he said, he was let out with the help of the Central Intelligence Agency.

In 2010, the focus turned briefly to the question of whether Mr. Taylor — who has denied ever carrying or trading diamonds — gave some gems to the supermodel Naomi Campbell13 years earlier in South Africa after a dinner with Mr. Taylor, Nelson Mandela and others on the eve of a celebrity charity event.

His lawyer raised all the subjects that had made him and his associates notorious: trading diamonds for weapons, widespread rape, cutting off the hands and feet of villagers, allowing Mr. Taylor to say that he would “never, ever” have permitted such crimes.

The many tales from his life, replete with details from his career as a rebel, a prisoner, a negotiator and a president, were followed by a large radio audience at home in Liberia.

No one knows exactly how many were killed or maimed in the intertwined civil wars of Liberia and Sierra Leone in the 1990s. Human rights groups have said that besides those killed outright, close to 4,000 amputees did not survive and up to 3,500 mutilated victims are believed to be still alive in Sierra Leone. Numerous former child soldiers are still in rehabilitation homes.

Original article can be found here: http://www.nytimes.com/2012/04/27/world/africa/charles-taylor-liberia-sierra-leone-war-crimes-court-verdict.html?

Adriane Ohanesian/AFP/Getty Images

South Sudan People’s Liberation Army vehicles drove along the road between Bentiu and Heglig Tuesday.

CASABLANCA — The Moroccan government’s cherished ambition to build a fast train linking its major cities is running into trouble.

The plan has provoked a debate not only about the wisdom of the project but also about what form development should take in a country as poor asMorocco: Should it be embracing potentially transforming technology or should it stick to basics like building schools and hospitals?

The high-speed rail link would be built with French help. It would link the country’s economic center, Casablanca, with the capital, Rabat, and Tangier, in the north. The project, expected to cost $4 billion, is to be financed by French loans and donations from Kuwait, the United Arab Emirates and Saudi Arabia.

Under the agreement, originally concluded in 2007, French companies, including the power and transportation engineering group Alstom, would build and operate the system, known in France as a T.G.V., for Train à Grande Vitesse. As envisioned, the completed project would cut a journey of 350 kilometers, or 215 miles, from Casablanca to Tangier from 4 hours and 45 minutes to just over 2 hours.

Critics say that a Western European-style train system should not be a high priority in an impoverished country. Per capita income is just $2,850, according to the World Bank. Morocco ranks 130th among nations in human development, a United Nations study found.

“You just have to take a look at the record level of illiteracy in our country, our failing health care system and the level of isolation of some regions that still live like they are in the Middle Ages, to understand that it is better to invest urgently in these areas to ensure sustainable development for Morocco,” said Salma Bouchiba, a financial analyst at Société Générale in Casablanca. “It is also quite legitimate to require first the improvement and the upgrading of the existing rail network that is in terrible condition.”

Supporters say that the rail line would bridge regional divides and improve the economy in the country’s north while strengthening links between Casablanca and markets and financial centers in Western Europe. Critics say economic conditions are too tough for Morocco to afford the high-tech system.

A leading opponent is Omar Balafrej, a co-founder and president of the political association Clarity Ambition Courage. This group is part of a loose coalition of about 50 groups known as Stop TGV! Their efforts include petitions, demonstrations and public debate. Their activities have led the transportation minister, Abdelaziz Rebbah, to agree to debate the critics in Rabat.

Mr. Balafrej says there is no justification for the project, which would strain Morocco’s already stretched public finances. “Every 10 meters of the T.G.V. is the equivalent of the construction of a school in the rural area,” he said. “Morocco ranks second-to-last in the region in terms of human development. T.G.V. advocates tend to convey the idea that this project would be carried by the French and the Saudis, but this is false. These countries give loans, not grants, to Morocco. The debt burden of the country will be obviously dramatically affected.”

But supporters say the T.G.V. would create jobs and lure investors.

The O.N.C.F., the National Office for Railways, says the high-speed links are necessary to accommodate increasing numbers of rail travelers. Some 34 million people are expected to use the existing system this year, compared with 14 million in 2003. The TGV is likely to draw 6 million customers, its promoters say.

“It answers a true need of Morocco,” O.N.C.F.’s managing director, Mohamed Rabie Khlie, said recently.

Critics say fixing the shortcomings of the existing system should come first. Najib Akesbi, an economist who teaches at the Institute of Agronomy in Rabat, said: “In Morocco, 40 percent of the rural area is cut off, and there are no roads. During winter in some villages, people remain blocked for months because of bad weather.”

He added that since independence, in 1956, “the rail system has barely budged” and that “there is still just only one track connecting cities.”

The cost would be steep because much of the financing is coming on commercial terms rather than as aid. Morocco would be left with debt service of $100 million a year, according to a study by Cap Democracy Morocco, a student group.