Transmission

Saleh Aljadeeah: 'Things can get, like, shockingly complex.’  

Narrator: Welcome to the second season of Transmission, the podcast of the Institute of Tropical Medicine in Antwerp. This season, we invite you to join our researchers in their never-ending quest for a healthier world. In this first episode, we will discover what happens when health systems crumble and can’t take care of patients anymore. And we take a closer look at a mysterious black box. Transmission, your front-row seat to the world of health, science and beyond.   

SFX: War

Narrator: Syria. 2011. War overturns everything. There is chaos and uncertainty.  

Narrator: And somewhere in that chaos, a pharmacist walks across the street. It's Saleh Aljadeeah, a man with a close-cropped beard, friendly eyes, and, despite the chaos, a positive attitude. A recent graduate of Damascus University in Syria, Saleh is on his way to a hospital under siege. 

Saleh Aljadeeah: ‘I would go to the hospital, I would walk. And, I mean, I remember like if I hear a bomb, you know, I know that when I will arrive, there will be a lot of bodies in the floor, like, on beds. You see, so that was kind of like a daily scene. Basically, I think, colleagues who were working there. They were also struggling to prioritize who to help, who not to help. You know, they cannot help everybody.’  

Narrator: During a war, your health system breaks down. People flee and are in chaos looking for someone to help them survive. Hospitals fill up.  

Narrator: It is 2011, and Saleh's whole life is turned upside down by the conflict in his country.  

Saleh Aljadeeah: Seeing how the conflict affected people access to health care in general, I realized that this is something. I mean, I can play an important role.’  

Narrator: One of the things Saleh noticed as a trained pharmacist is that during the conflict, people suddenly couldn’t get medicines anymore. 

Narrator: It wasn’t that people were looking for rare medicine. It could be something as simple as insulin, a diabetes medication that has been around for years and is available all over the world. But the crisis meant that access to drugs just stopped. Trained to deliver medicines to people, Saleh’s idea of what that meant changed during the war. 

Saleh Aljadeeah: medicines became also kind of...kind of a weapon you know in the conflict. So basically,on checkpoints, people are controlled. If they have a lot of medicines, this raises suspicion if they are being kind of involved in any activities to help certain groups of the population that should not get that help, you see? So, I've seen how medicines became much more than what we know as medicines.’ 

Narrator: Saleh goes to work in the Raqqa National Hospital, one of the three remaining hospitals in the Raqqa Region of Northern Syria, which now has to serve one and a half million people. The entire health system in the country has collapsed. 

SFX  

Narrator: A good healthcare system is invisible. It just works and helps people. Until it doesn't. 

Narrator: And then it becomes painfully obvious how much we depend on a functioning system to keep us healthy.  

Narrator: We will return to Saleh later. But to better understand his journey, we first have to open a box. It's a black box. And look: it is being delivered right now. 

SFX: Doorbell rings  

SFX: Transaction, postman hands over box 

Narrator: Perfect timing. 

SFX: Transition 

SFX: Open box, rip tape off box.  

Narrator: Imagine a black box. The box contains everything we need to keep you healthy. It contains things like quality medicine, well-trained doctors, pharmacists you can trust, and an accessible hospital that runs smoothly. At the bottom of the box, you will find protective equipment like face masks, and there is an ambulance for emergencies. Digging through the box, you will also find more abstract things. There are models to study why pregnant women die in childbirth, models to see how health care money is distributed and information to keep people up to date and prevent them from getting sick. And if you look closely, there are researchers in there waving at you. 

Narrator: Go ahead, you can wave back.  

Narrator: It really is a special box with extraordinary contents. And we give it a name: we call it our Public Health System. And it’s one of the priorities of the Institute of Tropical Medicine, or ITM, to make sure we understand how we could build public health systems that can withstand a shock. 

Lenka Benova: ‘Sometimes the box looks like it's solid. You just don't quite know how it works on the inside, but it seems sturdy, it performs, it hums on a daily basis.’  

Narrator: This is Lenka Benova, she works at ITM and focuses on reproductive and maternal health. She's on a quest to ensure that no woman ever dies in childbirth. It is the part of the health system that she feels most committed to. 

Lenka Benova: ‘But there are some signs, sometimes things are ineffective, inefficient, but you're not exactly sure why. But by the grace of God, it keeps standing there and looking good. So let's not tinker with it.’ 

Narrator: If you start to shake the box, things quickly become quite complex. And in a war,… 

SFX: Incoming sound of bomb, we're back in war territory

Saleh Aljadeeah: things can get, like, shockingly complex.’  

Narrator: This is Saleh Aljadeeah again. 

Saleh Aljadeeah: And on daily basis, we see, of course, how. I mean, first of all, the hospital became extremely crowded, you see. The challenging thing, of course, we had constant attacks on the hospital. This is something we see that it's becoming more common, that healthcare facilities are becoming targets of violence, of conflict, of bombardment. So that made it very challenging. Also, there was, let's 

Narrator: A lot of doctors gave up and moved to safer places. That, along with the constant influx of injured people, put a huge strain on the hospital and everyone who worked there. Or to put it euphemistically:  

Saleh Aljadeeah: ‘It is challenging. (…) I mean, I'm talking here about 2012, 2013 still the experience, I still have it with me until today, and I think that's the driver for the research I do, for the work I do.’  

Narrator: Today Saleh is a researcher at ITM. 

Narrator: War is an extreme example, but in several other countries, the system is also under pressure from creeping crises such as ageing, urbanization, climate change, or very recently: Covid.  

Lenka Benova: ‘What we were able to see during COVID is actually how such a big shock to the system broke things.’ ‘So what was the first thing that was affected? What was the link or the weakness that was exposed first? 

Narrator: This is Lenka again, researcher at ITM. The first thing to collapse during the pandemic was the supply chain that delivered protective materials to hospitals and healthcare workers. As a result, there were shortages across Europe. 

Lenka Benova: those are the things that looked on the surface as if they were working, but were not. And it's shocks like that that will expose the weak links.’  

Narrator: And that’s exactly what ITM alumnus Prashanth Srinivas found out himself, in a dense forest in India. 

SFX: Forest sounds, Leaves rustling. Birdsong, then  

SFX: Playful shouts in the distance 

Narrator: We are in BR Hills in India. BR stands for...

Prashanth Srinivas: ‘Bidigiri Ranganatha Swami, Tiger Reserve’,  

Narrator: but as Prashanth Srinivas says, 

Prashanth Srinivas: ‘you can call it BR Hills for short.’  

Narrator: Prashanth is an open person, quick with a laugh and friendly to talk to. He is director of the Institute of Public Health Bengaluru in India and together with his wife Tanya, they run a local community hospital and research facility in the territory of the Soligah people, an indigenous community with whom they work and live. 

Prashanth Srinivas: ‘They used to be amazing hunters until the wildlife laws, of course, prevent hunting anymore.’  

Narrator: The Soligah live in several villages scattered throughout the forest. 

Prashanth Srinivas: It's a thick forest. It has tigers, elephants, leopards, several species of deer, about 300 species of birds.’ 

Narrator: They are very good at tracking animals, and they collect honey. 

Prashanth Srinivas: One of the largest honeybees we have is the rock honeybee, which builds very large beehives. So they’re expert climbers over rocks and trees, and they're very good at harvesting honey, bamboo, and the multiple forest products has been their livelihood for a long time.’ 

Narrator: They choose not to embrace modern society, and that confuses people. Why would someone not want to live in the so-called developed world? 

Prashanth Srinivas: ‘The more and more I've lived and worked with them, I can see why they feel it's absurd. (…) But this has consequences.’ 

Narrator: It makes access to treatment and medication challenging. 

Prashanth Srinivas: ‘what do you do when you are suddenly hit by an elephant? What do you do when you're mauled by a bear? These things happen.’ 

SFX: Transition pause 

SFX: The sound of labored breathing and medical equipment beeping is fading in.  

Narrator: Covid entered the district where BR hills is located. 

Prashanth Srinivas: ‘we had three waves, I think, (...) in the first wave, we didn't get much affected. But in the second wave, you had a sudden kind of pouring of people into the hospital. And on one day, I think our hospital ran out of oxygen. (...) The system was not able to suddenly deal with a spike in the oxygen requirement, so the supply chains basically gave up.’  

Narrator: The health system in the district could not cope with the shock of Covid and collapsed.  

SFX  

Prashanth Srinivas: ‘That meant that critically ill patients who needed oxygen, 23 of them died that one day because the oxygen supply ran out there. It was a disaster.’  

Narrator: At that point, Prashanth and Tanya decided to move into the district hospital for a few months to help cope with the crisis. The hospital was 50 kilometers from their home in BR Hills and the most difficult question was what to do with their young daughter. 

Prashanth Srinivas: ‘We left the daughter with my parents. She was three years at the time, so it wasn't also very easy to stay away for such a long time.’  

Narrator: Life sometimes requires difficult choices. But the need that Prashanth and Tanya saw was too great. 

Prashanth Srinivas: ‘what is it that we did ultimately is merely providing a kind of leadership in a very chaotic situation. So trying to bring people together, how do you manage triage? You had patients who were running out of breath and sitting on the road and things like that. (…) A lot of people were just in a state of panic. Sometimes just receiving the person and making them feel that care will arrive soon is so much important and that was not happening. 

Narrator: Prashanth and Tanya had the capacity to help and they rose to the occasion. And they stayed. They later reunited with their daughter in BR hills and now live there permanently. Tanya heads the local NGO-run hospital and supervises new trainee doctors. Prashanth is focusing on building the research center. 

Prashanth Srinivas: ‘we call it a learning site, where mid-career to senior academicians can be based and they live within this learning site with strong relationships and partnerships with the community.’  

Narrator: A place where everyone trusts each other, where BR Hills residents can get involved and take control of their own health, and where, perhaps surprisingly, some of them learn to play....frisbee. 

SFX: People running around. A team is playing Frisbee.  

Narrator: Let’s have a look. 

SFX: Sports sounds, laughter 

Narrator: A group of young people are throwing around a frisbee, but they are not just playing frisbee, they are playing ultimate frisbee. A non-contact sport that has been shortlisted for Olympic consideration.  

Narrator: Why are they playing it here, in the middle of a forest in Southern India? 

Prashanth Srinivas: ‘The Soligah are about totally 25,000, 30,000 people. And not one of them is a doctor, not because they are not able to be, but because of various social and historical exclusions. That's really at the heart of the problem with many different indigenous communities in India.’ 

Narrator: Addiction is one of the things they fight in the community. 

Prashanth Srinivas: ‘For addiction, you can, of course, treat, that's one. You can provide care.’  

Narrator: But more interestingly, you can do prevention. And that’s what they try to do with Ultimate Frisbee. 

Prashanth Srinivas: ‘It's like football, but with Frisbee. (…) You make small ultimate Frisbee sports clubs among the indigenous youth, and then they form a spirit circle at the end of the game, and they analyze the game, and you try to bring in some kind of a life skills approach.’  

Narrator: You can teach them how to deal with conflict, and that's good for self-confidence. 

Prashanth Srinivas: ‘It's our understanding that there's a kind of a low self-worth thing. You don't question and you don't question authority. You sometimes suppress your feeling of frustration, et cetera.’ 

Narrator: And so Tanya and he are doing a study to see how they can use sports to deal with these challenges. From addiction to frustration. 

Prashanth Srinivas: ‘We hope that it could help them to choose health rather than having someone tell them that this is bad or that's good kind of thing.’  

Narrator: The beauty of the sport is that all genders can play together. 

Prashanth Srinivas: ‘Before this, we failed by starting with volleyball because the community said, we'll do volleyball, and it was just boys. (…) So it became a boys club. And Tanya was like, “What the hell is this?” And so then eventually we discovered this. And it's fascinating.’ 

Narrator: It's a fascinating health system indeed, right there in BR Hills, among the birds, the elephants and the bees. And it takes the work of a lot of motivated people to keep it running.  

Narrator: Let’s leave India for now and move back to Lenka Benova. Lenka regularly comes across harrowing stories in her quest for better maternal health care. Stories about what happens when your health system doesn’t function as it should. 

SFX: Sounds of a hospital ward 

Narrator: The girl is 19 years old, highly pregnant, she was hospitalized in her home country in the Democratic Republic of the Congo. Her baby died at birth. Broken with grief, she wanted to get out of the hospital, out of that place. But the hospital keeps her. She is not allowed to leave until she can pay for the care she just received. But she can't pay. And now she’s stuck. She sits in the hospital and waits until some miracle happens so she can pay off her expenses.  

Narrator: This story is not made up. 

Lenka Benova: This 19-year-old young woman has been here for two months because her family has just not been able to bring the payment for the fee. And actually then you learn that the baby that she gave birth to died. So she came, she has no baby to take with her, and she’s imprisoned, detained in the health facility for months.’ 

Narrator: Caring for pregnant women or helping out a new mother and her newborn child is self-evident in many countries, but it’s not. One of Lenka’s missions is to improve access to maternal health. To make sure that women don’t die in childbirth and get the care they are entitled to. It is not easy, because there are many reasons why things can go wrong in a hospital. 

SFX: Sounds of a busy hospital 

Lenka Benova: ‘When you imagine going into a referral hospital, whether it might be in Guinea or in the Democratic Republic of the Congo or in Uganda, what you see is a very busy maternity ward. And by busy, you can feel, for example, the number of women there might be more than the number of beds. So you will see women lying on the floor, women lying two to a bed. And the providers, the health care workers will be extremely busy.’ ‘in a five minute visit, the hospitals look the same.’  

Narrator: Two hospitals can be equally chaotic and busy 

Lenka Benova: but the reason why they look the same can be quite different.’ 

Narrator: Sometimes women do not receive timely care because of a lack of staff. But in some places, there are just too many staff because the system has trained and hired too many doctors. 

Lenka Benova: ‘And the problem that you get there is they need to get paid. So what does the hospital do is ask women for money. And so that hospital is going to be crowded not because too many women came, but because too many women are effectively imprisoned there for failure to pay the fees.’ 

Narrator: Detained. Held captive. 

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Narrator: The quest for a healthier world is truly a never-ending story. We can’t take our health systems for granted and we urgently need to better understand how our black box functions. So join us and the researchers in our second episode as we hear the stories of people across the globe who try to get access to health care and discover the challenges they face to even get something as simple as medication. 

Lenka Benova: ‘Well we wake up angry every day. That’s the way you get going, right? 

Narrator: Thank you for listening. For more information about the Institute of Tropical Medicine in Antwerp, visit ITG.be/podcast. 

Raffaella Ravinetto: 'At the moment, you have about 20% of the population of the countries worldwide are using almost 90% of the available morphine.'

Narrator: Welcome to Transmission, the podcast of the Institute of Tropical Medicine in Antwerp. This season, we invite you to join our researchers in their never-ending quest for a healthier world. In the previous episode we discovered we cannot take our health system for granted. But even if it functions, you need to be able to access it. So, in this episode we discover why access to health care is something worth fighting for. Transmission, your front row seat to the world of health, science and beyond.  

Narrator: Imagine. You and your partner are about to have a baby and you need to get to a hospital as quick as you can. You’re both in the car, but it’s not speeding to the clinic. In fact, it’s not moving at all. You’re stuck in traffic. As your worries mount, you realize you will never get to the hospital in time. 

Narrator: A crisis does not always have to be as big as a global pandemic. Sometimes it’s trivial things like structural traffic jams on the way to the hospital and a mother giving birth in distress. 

Lenka Benova: ‘When women cannot get to that advanced care, they will be dying in transport or not even reaching that facility.’  

Narrator: Lenka Benova is a researcher at ITM’s reproductive and maternal health unit. Together with partner organizations she works on improving maternal health care. We already met her in the first episode.  

Narrator: After the death of a woman, the hospital will typically organize a maternal death review to see what went wrong, and the responsible committee will take notes.  

Lenka Benova: And so you will find maternal death records, files, which will say “Dead on arrival” or you know “Died shortly after arrival”. So when it comes to the maternal death review, that committee will say, “Well, there is nothing we could have done. This woman was already arriving in such a state, we couldn't help her. But it's not our death,” they will say.’  

Narrator: It's not our death. It shouldn't be on our list. It's not up to the hospital. 

Lenka Benova: ‘And they are right to some extent, but it is our death in terms of a system, in terms of a society. And so these linkages, whether it is traffic or money for transport or ambulance prioritization for maternal cases are going to lead to death, perhaps the worst deaths of all, which are unaccounted for,’ 

Narrator: How does Lenka cope with the fact that this should have been a preventable death? 

Lenka Benova: ‘Well we wake up angry every day. That's the way you get going, right? You wake up and you know there is this huge injustice happening, whether it be for lack of political priority, lack of funding due to conflict and displacement, due to racism or socioeconomic marginalization. (…)  So we fight on and we do our research, we try to communicate it and push ahead. And you know luckily, we are not the only ones. There is a large community of researchers and implementers around the world who are all doing it. But that's what you have. You just have to believe that things are improving slowly every day.’ 

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Narrator: It’s not only that getting access to a good hospital might be impossible. Getting the medicines you need is not always a matter of strolling to the pharmacy either. 

SFX: Suddenly air alarm blaring, guns, bombs, ambulances, more bombs. 

Narrator: It is war, you sit exhausted on a chair, holding your last insulin shot. Soon you will have to go out again to find medicines to treat your diabetes. Or your epilepsy. But where do you find them? Outside is chaos, access to medicine is gone, the pharmacy you used to go to is in ruins, and the NGO that helped you with your care has left the country.  

Narrator: The fact that noncommunicable diseases such as diabetes and epilepsy are particularly challenging during a conflict is no surprise. 

Saleh Aljadeeah: Globally, noncommunicable diseases are among the most common reasons for mortality, and these are neglected in conflict zone.’ 

Narrator: It is a gripping story that ITM researcher Saleh Aljadeeah, who we already met in the first episode of this season, heard from a patient in his home country of Syria. 

Narrator: But even if you find a place that still sells insulin, you're not out of the woods yet. 

Saleh Aljadeeah: ‘On regular basis, the issue in the place where he lives in northern Syria, that in summer temperatures reach 40 or even exceed 40 degrees. So storing insulin is challenging in these settings, especially at the same time, you have electricity cuts.’  

Narrator: So, the question is not just whether you can keep insulin cold in a 40-degrees Centrigrade environment where the electricity is constantly cut, and bombs are exploding. It is also whether the person you are buying it from has done so.  

Narrator: What happens to the supply of medicines when war breaks out in a country? It is Saleh's quest to better understand this. 

SFX: Truck horn 

SFX: Truck moves, stops, gets stuck  

Narrator: Driving a truck through a conflict zone is not easy, even if you leave out the bombs and armed troops. 

Saleh Aljadeeah: ‘So checking points you see at the border, sometimes the medicines are held for a long time to kind of get the permission, but also the security issues, like you are waiting, let's say, with your truck for a time when the bombardment is kind of less severe, or sometimes you have cut off bridges so you cannot move forward.’  

Narrator: If the truck is delayed over and over, the medicines are getting closer and closer to their expiration dates. To the point where they are no longer usable by the time they get to their destination. And there is also something more insidious at work. 

Saleh Aljadeeah: ‘Another issue is donations. So we see that sometimes medicines that are donated are kind of close to expiry date.’  

Narrator: Because they are donated close to the expiration date, they are expired by the time they get there.   

Narrator: So, say you finally find a trustworthy pharmacy with an affordable drug, even then you don't buy more than one package. 

Saleh Aljadeeah: ‘many patients were telling me that, well, we don't do that because (…) it's obviously that by finishing the first package, then the second package is expired.’  

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Narrator: And even if you know a pharmacy that is trustworthy and has the medicine that you’re looking for, there is one final hurdle to take: money. Is the pharmacy charging a fair price? In most countries there is a fixed price for medicines you buy at a pharmacy.  

Saleh Aljadeeah: ‘This is not the case in a conflict zone. So each pharmacy has its own prices, and the patient goes from here to there. So they need to navigate the system to make sure that they get, let's say, the best price they can afford. But here, this is also very much linked to the quality you know. They need also to think about the quality of the medicine. And this is a huge burden on the patient you know to think about. Okay, is this medicine of good quality or not? Should I pay less?’ 

Narrator: Especially if you have a chronic disease like epilepsy or diabetes, it becomes a hell of a challenge. Because you need these medications. Whether you want it or not. 

Saleh Aljadeeah: ‘This is an issue we see in conflict zones. Families who have members with chronic conditions, sometimes they need to choose between providing food or medicines’ 

Narrator: Leaving you to sit there on your chair with your last insulin shot in your hand, wondering where you can get the next one. 

Narrator: And money is an issue everywhere, not just in conflict zones. 

SFX: Busy conference hall 

Narrator: The year is 2016 and we are in a busy conference hall. It is filled with researchers from all over the world. A researcher from Cambodia comes on stage. He has been invited to talk about his work with people with diabetes.  

SFX: Microphone feedback 

Narrator: He taps the microphone and tells a story about one specific encounter he had. A patient with diabetes looked at him and said. 

Raffaella Ravinetto: 'I wish I had HIV'  

Narrator: Raffaella Ravinetto, head of the Public Health Department at ITM, still remembers the talk vividly. 

Raffaella Ravinetto: “it was a provocation, but not that much, because as a HIV patient in Cambodia, this person would have received antiretrovirals for free. But with (...) with diabetes, you have to pay for the insulin, you have to pay for the syringes, you have to pay for the glucometers, and this is all out of pocket of the person, independent of the income of the person.’  

Narrator: The person would have been better off with HIV than with diabetes, because we pay much less attention to the non-communicable diseases like diabetes, cardiovascular disease or epilepsy.  

Raffaella Ravinetto: ‘By the way. It's not only the poor countries, every year there are people who die in the United States because they do not have health insurance. So that of lack of access to insulin are also reported in the United States.’ 

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Narrator: The forces that could keep a medicine out of reach are sometimes too vague to even imagine. During Covid, you saw rich countries start hoarding vaccines, up to the point where some of them could vaccinate every individual multiple times with all the vaccines they had gathered. 

Chris Kenyon: ‘And Southern countries had essentially zero vaccines.’  

Narrator: We hear Chris Kenyon, working as a researcher and as a doctor at the HIV clinic of ITM. We know that the global North has been hoarding vaccines to the detriment of the global South. 

Chris Kenyon: ‘South Africa was forced to send its COVID vaccines that it had made in its factory in Port Elizabeth to Europe because of patent issues and all the rest.’  

Narrator: Patents are a major gatekeeper indeed. 

Narrator: The same thing happened earlier with the availability of HIV drugs. 

Chris Kenyon: ‘When I first worked in South Africa, 40% of the patients we had admit would die within two, three days because they had AIDS and we couldn't do anything for them. And that was at a time when HIV medications were available. And so we were working in this knowledge that actually all of this was preventable.’  

Narrator: Like with the Covid vaccinations, patents were preventing the availability of medicines. It was only when there was mass protest that these drugs became available. 

Chris Kenyon: ‘And I think that's an incredibly valuable lesson. And it was disheartening to see in COVID that we actually hadn't learnt that much that we had to go through that same process again before vaccines became accessible in the South.’ 

Narrator: Or as Raffaela Ravinetto puts it: 

Raffaella Ravinetto: ‘Did we as international community learn from that experience? If we have another outbreak, global pandemic, and we will most likely have it, we know that we are able to develop a vaccine very quickly. Will we be able to deploy it immediately this time everywhere, and not starting from the US and the EU and Canada? At the moment the answer is not.’  

Narrator: Three and a half years after the start of the pandemic, we are still discussing patents and whether we should be able to open them up when the need is high. 

Raffaella Ravinetto: ‘No, we are not there.’ ‘And if a next epidemics outbreaks comes and we are in the same situation that we have a vaccine and we don't know how to make it available to everybody immediately, that would be really a moral defeat of our society in the way it is organized now.’ 

Narrator: Equal access to the medicines we need is far from a given, but nowhere is it more evident than in the world of painkillers. Drugs we need to operate on the sick and keep people from suffering 

‘Raffaella Ravinetto: There is an incredible imbalance in access to these medicines like morphine, which are essential to treat severe pain. At the moment, you have about 20% of the population of the countries worldwide are using almost 90% of the available morphine.’  

Narrator: There are a lot of countries in the world where they can't give you morphine to relieve pain. Whether you're in intensive care with terminal cancer or you're having surgery. Just because morphine is not available. 

Raffaella Ravinetto: ‘When you have a war, the needs in morphine will increase because you will have more wounded, et cetera. And that's very difficult for the country to get... to procure this product in an emergency. And we have read it recently, hospitals in Gaza doing surgery without anesthetics or without post-surgery pain therapy. But it may be the same in Niger, it may be the same in Sudan at this moment.’  

Narrator: Why don’t we make more morphine then? For one reason, morphine is an old drug that anyone can produce, which makes it less interesting for companies. But morphine is also subject to strict regulations to prevent drug abuse. With the unfortunate result that, for example, regulations designed to prevent abuse in the United States, have a very  real impact on the availability of morphine in low-income countries. The system surrounding the drug is complex and involves a lot of financial, cultural and legal hurdles. 

Raffaella Ravinetto: ‘But really, if you look at this figure, you see the countries with access to morphine and the countries with no access to morphine. It looks like the colonial maps of the 19th century. You see that the morphine is in the former colonial power and not in the former colonies. This should be a scandal for every journalist around, but it's not very much discussed.’ 

Narrator: Equal access to health care is not only a problem for countries in the Global South. For example, PrEP - the drug that can prevent you from getting and spreading HIV - is far from available everywhere.  

Narrator: Chris Kenyon talks about sex workers in Antwerp: 

Chris Kenyon:’It's still not really available in sufficient quantities worldwide. There's still many, many populations who don't have access, like I said, here in Antwerp, in fact, the ‘Schipperskwartier’ is a few hundred meters from here. And there's people there tonight who are going to be having unprotected sex because they can't get prep. (..) So it's happening here, (…). There's many, many populations that are not getting enough PrEP.’ 

Narrator: But we must not fall into the trap of pointing fingers. 

Raffaella Ravinetto: ‘When you talk about access to medicine the discussion gets very easily polarized. We come from situations in the past when it was very easy to find a guilty one. So...ah! it's the industry, oh no, it's the patient who doesn't understand, oh, it's the government who's not committed enough.’  

Narrator: It's never one person's problem or one person's fault. 

Raffaella Ravinetto: Everybody should act to improve it. In other cases, it’s more straightforward but we should really avoid this kind of polarization.’ 

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Narrator: Let’s say the stars align. Everything works in your favor: there is a well-functioning health care system, the prices of medicine are under control, the patents are cleared. And still, you don’t get the medicine. Why? Well, sometimes it is the lack of information that is keeping you from getting access. Take PrEP again. One of the people who was ready to take PrEP from the beginning was Tim Devriese. 

Tim Devriese: ‘I heard about PrEP for the first time in New York, like casually at a gay bar. I was fascinated and I didn't know what it was.’  

Narrator: Tim is a patient at an HIV/STI clinic in Belgium. He’s always on the lookout for more information. In Belgium there are twelve clinics where you can go for HIV and STI treatment without fear of being judged. ITM hosts one of those clinics where countless patients are helped every year. These are safe places where you can talk about your concerns. 

Tim Devriese: I've been very, very preoccupied by that part of my identity, figuring out what it means, how other people have interpreted it, how other people have dealt with it, how other people have expressed themselves. (…) when I was growing up, (…) sex didn't exist. It...didn't exist. It was never part of any conversation.’ 

Narrator: But then the word was out: there was a drug that could prevent HIV infection! It wasn’t yet available in Belgium, until suddenly, in 2017, an email arrived in Tim's inbox. A press release from the Ministry of Public Health saying that PrEP would now be available AND reimbursed.  

Tim Devriese: ‘I just saw the title and I dialed the clinic to ask if I could get an appointment and to get this show on the road. So I think I was probably one of the first, because the news wasn't even out yet you know, I just had the e-mail. I was probably one of the first. 

Narrator: When PrEP became available, Tim's life changed. 

Tim Devriese: ‘It changed completely. I've noticed that I'm, sexually speaking, more carefree. I feel more emancipated about the choices that I make. I think it's a godsend. I'm very, very grateful that it exists here and that it exists for so many people. I just hope that more people who need it get access to it and use it properly and understand what this means not only like medically, but also mentally, psychologically, and all that sort of stuff. Yeah, it was a life changer, absolutely. Yeah. 

Narrator: A wonder drug, but what do we see? For a bunch of different reasons, a lot of people whose lives would be changed for the better don't take it. A lot of uncertainty and ambiguity remains. Again, researchers have to find out why people can’t access the drug or don't use it. The hardest group to help are often undocumented people; it is a huge challenge for doctors to get them into proper treatment. But that's mostly because of the rules. Chris Kenyon explains:  

Chris Kenyon: ‘There’s a lot of people here who are not legally here, who are not entitled to HIV PrEP, and they're frequently dependent on sex work. So both for themselves, for their own health, and for the public health, it would be logical to give them this medication that's fairly cheap, very effective at preventing HIV. Tragically, we still are unable to give all those people the medication they need to prevent HIV, which is, I think, very short sighted as a society.’ 

Narrator: The barriers to a sexual health system that is accessible to all are many. Tim sees this happening regularly. 

Tim Devriese: ‘Well I think there's a lot of high bars. I think health, especially sexual health, because that's the field of medicine that I you know quote-unquote, specialize. I'm not a specialist, obviously. I'm more of a habitual connoisseur. It's very system-focused. The system is central and then the patient has to sort of adapt to the system.’ 

Tim Devriese: ‘It's all very confusing. It's very, very confusing, and there's never like a single entry point. There's so many different places where you can go that it becomes very diffuse and difficult for a patient to find the right info and the right help. I mean, the help is there. I am very happy with the support and the service that I and the care, really care, that I get.’ 

Tim Devriese: ‘But everything that's self-evident to you is not self-evident to somebody else. And it's in those cracks, that's the cracks that people fall in between, right?.’ 

-----  

SFX: Building and painting sounds 

Narrator: We leave the HIV-clinic and go to Zambia where young people are renovating a house so they can take the access to their sexual health into their own hands.  

Narrator: A place where they feel safe amongst their peers. 

Narrator: It’s a very special house. 

Bernadette Hensen: ‘We wanted to create a place where young people felt like this is something for us. 

Narrator: HIV-rates and unplanned pregnancies are high among adolescent girls and young women in Zambia. On top of that young men are less likely to know their HIV status or think about family planning. That’s why ITM researcher Bernadette Hensen was looking for ways to get young people between ages 15 to 24 in Zambia to think about their sexual health. Interviews quickly revealed that young people wanted a place of their own where they could talk about sex, consent, HIV, relationships, or where they could get menstrual products or condoms.  

Narrator: They were not at all eager to use mainstream health services. 

Bernadette Hensen: ‘It’s often that they shouldn't, quote-unquote, be having sex. And yet often many of them are. And by going to the health facility for something, you're disclosing that to someone and often someone a lot older than you. One of the things they said is, well, we don't want to go to the health facility because sometimes it's our auntie who works there, or we're in a queue with a lot of pregnant, older women who know our parents. So they wanted services in their communities.’ 

SFX: building, renovation 

Narrator: And that's why you hear carpentry. Young people have teamed up with the local organization Zambart and Bernadette. In different villages they build places where they feel comfortable. It’s community participation at its best.  

Bernadette Hensen: ‘They chose the logo, they chose the colors. And then peers, a little bit, usually around the age of 20 to 24, would provide the services. And they weren't just HIV testing. It wasn't just condoms. It was very comprehensive, including comprehensive sexuality education, menstrual hygiene products for the young women and girls, contraceptives, edutainment.’  

Narrator: The screenings of the MTV show Shuga, a television series about HIV, sexual health and consent, were wildly popular. On those nights the building was packed.  

SFX: Sounds of TV, young people laughing (05:51)  

Bernadette Hensen: ‘There were lots and lots of young people there because they were very keen for knowledge, right? Everybody wants to understand things.’ 

Narrator: Bernadette’s mission is to find the barriers that keep people from seeking health care and to break down those barriers so they can get access to it. 

Bernadette Hensen: ‘I'm just very intrigued by how we behave, what drives our behaviors.’  

Narrator: Because that in turn has a strong influence on how we can improve our own health. 

Prashanth Srinivas: ‘For me, at the heart of that is dignity, the ability for people to walk into health centers or healthcare experiences which are dignity enhancing.’  

Narrator: We hear Prashanth Srinivas, the ITM-alumnus we met in the first episode of this season. 

Prashanth Srinivas: ‘I think that's very, very vital and important. Why do I say that? It's because in several countries, including perhaps in high-income countries, healthcare experience is not enhancing dignity for a lot of people. It's disempowering, it's transactional, and that's at the heart of why people do not seek professional help.’  

----- 

SFX: Whispers, rustling of papers. Someone getting seated at a doctor’s office 

Narrator: Imagine you are told that you have HIV. Fortunately, medicine has ensured that it is no longer a death sentence in a lot of countries.  

SFX: Pop a pill from a blister  

Narrator: There are also pills to treat other sexually transmitted infections, or STIs for short. What the drugs cannot do, however, is remove the stigma that society still all too often adds to the mix. 

Chris Kenyon: ‘What we find is that there's still a lot of, unfortunately, doctors, nurses who stigmatize STI. We still have patients who come away feeling awful after a consultation.’  

Narrator: This is Chris Kenyon again. (51:33)  

Chris Kenyon: ‘Taken out of the doctor's office in front of all the patients in the waiting room and being told in front of everyone: “this one has HIV”, that sort of thing. It still happens in Belgium in this year.’  

Narrator: Too many people are still stigmatized because of their sexuality or the sexually transmitted infection they have. Chris is passionate about making people not only healthy, but also happy. He wants the ITM clinic to be a safe place where people can go without fear of being judged.  

Chris Kenyon: ‘Yeah I mean, we're there for them, we’re there to improve their health.’ ‘We don't want to just prevent them getting STIs. We want them to live a healthy, fulfilling sexual lives, and we wanted them to do that in a safe way as possible. And then we want to be there for them. If they have STIs, if they get symptomatic, we want to make sure that we can give them optimal treatment.’ 

Narrator: Tim Devriese regularly visits an HIV/STI clinic to get information and strongly believes in the importance of living a healthy, happy life. 

Tim Devriese: ‘Especially when it comes to sexual health, I think happiness has to be a part of the equation.’ 

Narrator: And we need to put the care back into health care. 

Tim Devriese: ‘there should be a big focus on the clinical aspects of health care. But I think specifically for this topic. And people need to be cared for, listened to’. 

Tim Devriese: ‘I really have to applaud everybody. I never once experienced a judgment call or shame. Or...the care was provided, it was very emancipatory as well. It wasn't paternalistic. They were not like... It was very like, you have this in your hand. Let's talk about it.’  

Narrator: In the quest for a more robust health care system, you cannot lose sight of dignity or hidden factors like stigma or people's lifestyles. You need to involve the community and listen to them. 

Narrator: As the Covid vaccines became more widely available for example, a lot of communities were suspicious. In many places they thought they were getting the leftovers, the waste from the richer countries. That didn't make the challenge of convincing the whole world to take the vaccine any easier. Let alone that you want to vaccinate remote communities like the Soligah people living deep in the Indian forest. Prashanth took on the task but had to find the right angle to approach the problem. 

Narrator: Prashanth has lived and worked with the Soligah community for years, but when the vaccines arrived, people were suspicious. 

Prashanth Srinivas: ‘when we had to convince indigenous people living in fairly remote settlements that this vaccine will save your life, many of them were asking: “how come that our life is so precious to save, and this vaccine is going to do it?”  

Narrator: People in our villages are dying from so many other things that are not being addressed, they said. We have been asking for roads or water or other basic things for so long. And now this vaccine is going to save our little village in the mountains? They were skeptical. 

Prashanth Srinivas: ‘Many of us were dumbfounded. What do you say to this? How do you even respond to the fact that people are saying, “I don't have roads and water, and now the COVID-19 vaccine is going to save your life?” It posed a very important ethical question.’ 

Narrator: The approach had to be different. And so, Prashanth's wife Tanya went on a big tour. 

Prashanth Srinivas: ‘So she toured about 80 to 90 of the 148 tribal villages in our district, in deep forest areas, spending a day each.’  

Narrator: She didn't do this tour alone. She was accompanied by a full street theatre. 

Prashanth Srinivas: ‘We worked with a folk artist called Basavaraju. He created a whole street theater routine about how the virus originated in China, but it wasn't their mistake, but it's now come everywhere. It's now at your doorstep. He framed the vaccine as a right. He said others are taking their rights. Will you get left out of your rights now, just like we got left out earlier. He framed it so beautifully through a dance drama, which was performed in each of these 148 settlements.’ 

Narrator: After the street theater there was a debate where tempers sometimes ran high.  

SFX: Sounds of a busy town meeting 

Narrator: People were for it; people were against it.  

SFX: Animated conversations  

Narrator: But in the end, the team achieved a vaccination rate of over 90% in the area. People took their right to get access to the vaccine.  

Prashanth Srinivas: ‘That was a really fulfilling experience and it really showed for us the power of community engagement when you do it.’  

Narrator: By getting the entire community involved, you can get extraordinary results. 

Prashanth Srinivas: ‘And later after that, when people ask what survives from COVID, did any of the systems, lessons, survive from COVID? Not much, actually. But one thing survives is the Karuna Maari dance. So Basavaraju continues to perform it as a reminder for tourists who still visit to our village. He still performs the Karuna Maari dance, and he tells the story of how my group of folk artists helped with getting my community the vaccine.’ 

-----

Narrator: Do we not learn from our mistakes? Is access to health care not a given? As Chris summarizes:  

Chris Kenyon: ’Well, like I said, I don't think so, no. I think we have to fight that same fight every few years that our memory is very short. It's something that we need to keep on fighting for.’ 

Narrator: Fortunately, the researchers at ITM and their partners fight that fight every day to give more and more people access to health care. It’s a global challenge, rooted in global inequalities. All over the world countries are strengthening their capacity to regulate medicines and provide access. They make real progress. So that step by step, we evolve into a world where health for all is possible.  

Raffaella Ravinetto: ’And the results were quite frightening. We found that 27% of the medicine tested in the study, were seriously underdosed.’ 

Narrator: Thank you for listening, and please join us for episode three, where we discover that access to health care isn’t everything. All over the world people worry about the quality of the care they get. Yet another puzzle to solve. For more information about the Institute of Tropical Medicine in Antwerp, visit ITG.be/podcast. 

Lenka Benova: ‘One of our mantras in the unit is: women aren't stupid. And that is always a good motto to live by.’ 

Narrator: Welcome to Transmission, the podcast of the Institute of Tropical Medicine in Antwerp. This season, we invite you to join our researchers in their never-ending quest for a healthier world. In the previous episode, we tried to conquer the hurdles the world puts in our way when we want to access health care. But as we’ll discover in this third episode, you’re nothing with access if it lacks quality. Even for something as simple as cough sirup. Transmission, your front-row seat to the world of health, science, and beyond.  

SFX: Child laughing, child drinking, child coughing  

Narrator: Diethylene glycol is a colorless substance that mixes easily with water and is used as an industrial solvent.  

Narrator: You may be wondering why we're telling you this.  

Narrator: Diethylene glycol is something you don't want in your body. If you swallow too much of it, your kidneys will stop working and you will die.  

Narrator: Diethylene glycol can be a contaminant in the production of glycerin. And glycerin...is used to make cough syrup. So much for the theory. Now the practice. 

Raffaella Ravinetto: ‘Last year in The Gambia, some hundred twenty children died. Children younger than five years, they died of acute renal failure because they took this kind of contaminated syrup.’  

Narrator: We are listening to ITM researcher Raffaella Ravinetto. 

Raffaella Ravinetto: ‘The first doctor who notified there is something wrong here, did in July, and it was only in October that these medicines was withdrawn from the market.‘ 

Narrator: The Gambia case shocked people around the world, and investigators everywhere took a closer look at cough syrup. 

Raffaella Ravinetto: ‘And since then, we had cases found in Indonesia, in Uzbekistan, in Iraq, in Cameroon, and in some islands in the Pacific.’ 

Narrator: Can you feel it tickling in your throat already? Do you feel yourself looking at cough syrup a little more suspiciously? Do you feel how quickly this story undermines your confidence in a simple medicine? That's the problem, says Raffaella. 

Raffaella Ravinetto: ‘You need to have a pharmaceutical system which works on quality, affordability, supply, et cetera, and which is trusted by people. And if people do not trust the system, then people will say,(…) ‘You tell me that this medicine is safe, but I don't believe you’.’ 

Narrator: In most countries, if you go to a pharmacy, you buy medicine without asking too many questions. 

Raffaella Ravinetto: ‘We don't ask ourselves: ‘am I buying a product which will deliver the promises in the label?’ I don't ask myself, ‘is it safe’? ‘Will I get sick because of some impurity in this medicine?’ We just trust that somebody somewhere has checked all these things.’ 

Narrator: And in many countries, this is actually the case. There is a government agency that checks whether pharmaceutical companies are producing and marketing good quality medicines. But many countries do not have the resources to add such an inspection body to their health systems. 

Raffaella Ravinetto: ‘So not having the capacity to make all these checks, there is the possibility that a medicine comes to the market even if the quality is not adequate.’  

Narrator: Maybe the active ingredient, the substance that is supposed to make you better, is not present in the medicine in sufficient amounts. Or the medicine may even be falsified.  

SFX: Road 

Narrator: A few years ago, for example, ITM researchers and their colleagues from the Democratic Republic of the Congo took to the streets of Kinshasa to test the quality of antibiotics for children. 

Raffaella Ravinetto: ‘And the results were quite frightening. We found that 27% of the medicine tested in the study were seriously underdosed.’  

Narrator: In other words, 27% of the drugs on the market simply didn't work. If you give them to a child, they're not going to get better. 

Raffaella Ravinetto: ‘And that's very dangerous because the child will not recover. But you don't understand why. You think it is because of the disease. Even worse, you think that because the mother didn't follow the good schedule - it's not the fault of the mother, it's the fault of the medicines.’ 

Narrator: How do we get to a world where we can provide everyone with quality medicines at an affordable price? This is the mission that Raffaella has set for herself. 

Raffaella Ravinetto: ‘Without that, you cannot achieve health, and especially not health for all.’  

Narrator: But there are huge inequalities in the world.  

Narrator: According to the World Health Organization, at least 2 billion people do not have access to medicines or are at risk of taking poor quality medicines. There’s a lot of work to be done. And not only in the field of medications. 

SFX: Sounds of a child being born, a hospital  

Narrator: If you don't have a whole battery of experts and quality services present, women die in childbirth. In some countries, maternal deaths are meticulously tracked, but in others, many mothers die ‘outside the system’, far from hospitals and doctors. The differences between countries can be huge. Countries like Belgium, Iceland and the Netherlands top the list of countries with the lowest maternal mortality ratios 

Lenka Benova: ‘These are the countries where we look at and say: this number is possible, this low level of maternal mortality is possible.’  

Narrator: Lenka Benova is an ITM researcher in reproductive and maternal health. She strives to get quality care for women everywhere. 

Lenka Benova: ‘Therefore, it can be achievable anywhere else. And all the additional deaths, all the excess deaths are preventable, we have just chosen not to prioritize it.’  

Narrator: A cold but accurate analysis. People are falling through the cracks everywhere. 

Narrator: This must change. And that's why Lenka is working together with researchers across the globe. 

SFX: Airplane, city sounds, street sounds 

Narrator: We have arrived in Lubumbashi. The second largest city in the Democratic Republic of the Congo, at the very bottom of the vast country, near the border with Zambia. Whichever way you look at it, Lubumbashi is a big city. A national economic and industrial center where more than two million people jostle for space with cars, motorcycles, trucks and minibuses. Each with their own plans and perspectives.  

Narrator: And somewhere in this hustle and bustle, Lenka is sitting on a bench with one of her Congolese colleagues.  

SFX: A man counting in Congolese-French 

Narrator: And they are counting. 

Narrator: There is a big book on her colleague's lap. 

Lenka Benova: ‘We went together with one of the data collectors who now is sitting on a bench, on a terrace in a small private health clinic with the register in his lap, and he's counting how many births there are’  

Narrator: His finger slides through the book. How many C-sections have there been. How many complications, how many deaths. 

Lenka Benova: ‘And as he goes through this very neatly completed register book, you are seeing on the side a woman's name, of course, the birth weight of the baby or two babies. You might have twins. Every month there might be one or two sets of twins.’ 

Narrator: But then...

Lenka Benova: ‘And inevitably on every page, which might have 30 or 40 women listed there who gave birth, you will see one or two in the very last column that will say ‘mortney’, which means a still birth. And just having this in your face page after page after page, you begin to understand both where this data come from, but also just how heavy this burden is in places that, you know, where women are either not near the facilities, they are not able to afford the care on time, or the providers are unable to refer or give the quality of care.’ 

Narrator: Suddenly they are no longer numbers, they are women. 

Lenka Benova: ‘Every single one of these numbers that we use they all capture a very...a life, a unique life set of choices, set of non-choices that you know reflects a human being.’  

Narrator: Women who were lucky, or women who left the hospital with unbridled sadness. But then Lenka noticed something else. The hospital where they were now sitting had added an extra column to the normal data showing how much cervix dilation the women had when they arrived at the facility. 

Lenka Benova: ‘And so this is usually a number between zero and 10. When you're 10 centimeters, you are, you know, pushing.’  

Narrator: In cities like London or Antwerp, you see a lot of women arriving with two, three centimeters dilation, with many hours of labor still ahead of them. But in this case, in this tiny hospital, Lenka kept staring. 

Lenka Benova: ‘I kept looking at that column, and it would say seven, eight, six, nine, very high numbers. And when you look at the woman who arrived at nine centimeters, the hour of arrival is 18:50 and the time of birth is 18:57. I mean, she just made it. And that could have two reasons. A is because there was trouble on the way, there was delay, she couldn't find transport. But there is another reason...women don't want to be in health facilities that they don't trust, so they wait until the very last moment to hand themselves over to this unfamiliar, hostile, unpredictable, uncontrolled environment.’  

SFX: Bip bip (heart rate monitor) 

Narrator: A simple look at a birth register raises many questions. Why do women arrive so late? Is it because they don’t trust the quality of the care? 

SFX: Bip bip 

SFX: Bip bip biiiiiiiiiiiiip (heart rate monitor stops) 

Narrator: The inevitable has happened. A woman has died in childbirth.  

Narrator: Now, as a doctor, you know that a whole machinery will be set in motion to make sure that doesn't happen again. And that machinery is set in motion with a meeting called ‘a Maternal Death Review’. Where all parties sit around a table to discuss what went wrong and how to prevent it from happening again in the future. A very useful activity in theory to raise the level of quality, but not so easy to set up. Imagine you are the doctor who was on call when the death occurred. Can you already see all the fingers pointing in your direction? 

Lenka Benova: ‘So there are anecdotally hospitals in China where maternal deaths are not allowed. The spirit or the motivation of that is good because what you’re saying is ‘Let's work together, make sure everybody's on board that these deaths do not happen, that we recognize them, treat them. We are prepared’. Of course, what happens in that kind of situation is that the incentive will be if something happens, if a maternal death happens, it will be in everyone's incentive to hide it rather than to learn from it.’ 

Narrator: And so you arrive at one of the biggest obstacles for a world with fewer maternal deaths: we should learn from every death, but... 

Lenka Benova: ‘Practically, it's incredibly difficult because the blame and the shame and the sadness around the death is hard to manage. So it's much easier to say, ‘Well, it was his fault for not being here. He was on call. Why wasn't he here in the hospital?’ As opposed to thinking about the health system.’  

Narrator: Changing an entire system is difficult, takes a long time, and requires a lot of work from everyone involved. It is easier to point to an individual doctor. Christelle Boyi Honsou is an ITM alumna and now a researcher at the Centre for Research in Human Reproduction and Demography in Benin. She made it her mission to approach these reviews differently, in order to reduce maternal deaths in her home country. (02:33)   

Christelle Boyi: ‘We can say now in Benin that we have about seven mother who dies daily while giving birth or within the 42 days after delivery.’  

Narrator: In 2022, the country recorded more than 1900 maternal deaths. However, many deaths are not reported, because women may die at home or after an unsafe abortion without the involvement of the formal health system. This leads to estimates as high as 2,500 maternal deaths and despite substantial government efforts, this figure ranks Benin 13th in the world for the highest maternal death ratio. Christelle hopes to turn the tide. It is a challenging task because hospitals are understaffed, and people get stuck in their ways. As a result, review meetings don't always go smoothly. 

Christelle Boyi: ‘These sessions are expected to be conducted with the principles of the no-name. Nobody should know who the main provider who gave care to the woman, for example. It is expect that no blame should come after this review, whatever is found to be the factors that led to the death.’  

Narrator: But the reality is often different. It’s hard not to feel blamed during the maternal death review sessions and many factors are at play. As a result, the real problems that led to the women's death are usually not correctly identified.  

Lenka Benova: ‘So you will come up with a different solution, but perhaps not addressing the problem that is there on the big level. Then it’s easier to say, ‘Well, we didn't have blood, or that person wasn't there. Or even worse: ‘the woman came late. So now it's her fault that she died or her family’s.’ 

Narrator: But more often than not, the story is much more nuanced. As Christelle and her colleagues discovered when they were researching maternal deaths and the review process: somewhere in Benin, a pregnant woman died. No, not on a delivery bed in a hospital. She died at home in her village, away from the hospital. But why there, when there was a big hospital nearby that could have helped her? In a normal review process, the answer would be simple: everybody would gather around the table and point to the woman who didn't come to the hospital. Stupid woman. Not our problem. Case solved. But as Lenka says: 

Lenka Benova: ‘One of our mantras in the unit is: women aren't stupid. And that is always a good motto to live by.’ 

Narrator: So why didn't the pregnant woman get to the hospital in time? Her baby was stillborn. Did that play a role? During their research Christelle and her colleagues discovered that sometimes midwives delayed calling the gynecologist for a Cesarian section. They did so with the best of intentions. They didn't want the woman to lose their baby and have to deal with a Caesarean section 

Christelle Boyi: ‘They just try as much as possible to help this woman to deliver, to have a vaginal delivery.’  

Narrator: The result of this well-meant action? More women died in childbirth while delivering their stillborn babies. But it wasn’t the fault of the midwives either. In this particular case, it was an issue of trust between the different parties that were involved. Something that’s hard to figure out during a standard maternal death review. Fortunately, Christelle and her colleagues co-developed a new review model that looks at the underlying patterns and structural issues. This new model also includes near-misses and the mindset of the different health care workers involved in the care of women. After very successful pilot projects, Christelle's next step is to talk to policymakers to hopefully implement her new review model across the country. In doing so, she is having a very tangible impact on the quality of care and the number of mothers who die in childbirth. 

Christelle Boyi: ‘Now I can say that I'm proud of that. Because I'm proud of the way people feel during the implementation, the piloting of this model. And we are convinced that if we act on this, it will surely reduce maternal death in our institutions.’ 

Narrator: The stories are compelling, the work seems endless. Christelle and her work made a real impact, and that’s what keeps her going. Every researcher has such a flame burning inside. What would Lenka Benova say if people in a bar asked her what keeps her motivated? 

Lenka Benova: ‘Actually, I would tell them my own story, to be perfectly honest, is when I gave birth myself, I developed not a serious, but a very painful condition about a week later. And I had to be readmitted to a hospital for euhm... for some treatment for a couple of nights. And when I arrived at the hospital, and this was in London, it's irrelevant where it is because this is a story that is very much global. The point of the story can be placed anywhere. And this was a busy inner London maternity ward. And, of course, everybody was very busy taking care of women who were giving birth at that time. So to get diagnosed took many hours because every set of doctors that came was immediately called to some other woman who needed their attention more. And so by the time it was the nurse came to take some blood for the lab, I was so tired and stressed that she couldn't actually get a drop of blood out of me. She couldn't find my vein. And she walked away frustrated. And a midwife came, and I'm just in a very busy ward covered just with curtains. You can hear every other woman on the floor. And she came and she touched me and she looked me in the eye, and she said: ‘can I make you a cup of tea, love?’. And I said: ‘yes, please’. And she brought that cup of tea and a buttered toast. And it was the most kind gesture that I have ever felt from a health system. And I'm tearing up now, you can see it. But it was just the way she looked at me as a human. And she said, ‘gosh, this lady is exhausted and stressed. We are not going to get an IV-line in her unless she relaxes’. And I wish that for every woman that she's seen as a full human being, not just a womb, not just a contraceptive, not just as a problem, but to be taken care of kindly and humanly in a health system that can meet even social, psychological support issues.’ 

Narrator: So that’s the story Lenka tells people over drinks when they ask about her motivation.  

Lenka Benova: I'm not much fun in bars, eh? 

SFX: Sounds of miners, somewhere a canary whistles 

Narrator: Do you know the story of the canary in the coal mine? Miners used to take a canary with them underground. The bird was supposed to warn them of a lack of oxygen or if toxic gases were released during underground digging. The bird did not do this by whistling a warning song, but by dropping dead.  

Narrator: When the fragile canary died, the miners knew that something was wrong and that they should leave the mines as fast as possible. A dying mother is the canary in the coal mine of our health care system.  

Lenka Benova: ‘When a pregnant woman dies, we know something is wrong in that system that didn't take care of things the way that it should have done.’  

Narrator: It is a powerful signal that something needs to change. When a country gets its maternal mortality under control, it means the quality of the whole system is improving. 

Lenka Benova: ‘Because, to take care of a woman in her reproductive life who is pregnant, who is giving birth, who needs postpartum assistance, who might need family planning again, you need the entire range of services, starting with community awareness, community distribution of bednets to primary care services, for example, immunizations, antenatal care, measuring of blood pressure, measuring of the growth of the baby, all the way to extremely advanced hospital level care, which is, for example, Cesarean sections, blood transfusions, care for rare and intense complications that women endure.’ 

Narrator: There are many obstacles in our path. You shouldn't have to worry about the quality of your medicine or whether a hospital will treat you safely. But all over the world, people do. All the time. We need quality healthcare, before the canary dies. 

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Narrator: Thank you for listening and join us for the fourth and final episode of this season as we delve deeper into the question of how you can prepare your health system if you don't know what crisis is coming. The answer lies within all of us: we must become more resilient. But that is easier said than done. 

Bruno Marchal: ‘I heard some people talk about what we'll do now is prepare for 100 different kinds of crises, so that we have a crisis plan for each shock that will happen. Which is nonsensical.’ 

Narrator: For more information about the Institute of Tropical Medicine in Antwerp, visit ITG.be/podcast.  

Bruno Marchal: ‘Shocks that happen to us are one not predictable. What you can expect is that they will happen again, but you don’t know which one.’ 

Narrator: Welcome to Transmission, the podcast of the Institute of Tropical Medicine in Antwerp. This season, we invite you to join our researchers in their never-ending quest for a healthier world. In the previous episode, we took a look at the quality of our health systems - or the lack thereof. In this fourth and final episode, we unravel the question: What can we do when a crisis hits, and how can we prepare our health systems? Transmission, your front row seat to the world of health, science and beyond.  

SFX: Newsflashes 

Narrator: Around the world, crises are putting people's health care under pressure. There are fast attacks like Covid and war or slow, more insidious challenges like climate change, an aging population or urbanization. What will be the next big shock that we need to prepare for? 

Bruno Marchal: ‘I think nobody can say. What will happen is, of course, that we will get shocks.’  

Narrator: We listen to Bruno Marchal, researcher at ITM. He is a quick thinker and a fast talker with grey hair, glasses and a broad view of the world. ‘ 

Bruno Marchal: But what kind of shocks? We never expected that COVID would hit the way it hit. We never expected that the war in Ukraine actually had kind of knock-on effects economically, socially, politically, all over the world.’  

Narrator: Things are getting more complex. As gas and energy supplies around the world were threatened by the war in Ukraine, other houses of cards were toppled. Healthcare trembled. 

Bruno Marchal: Countries like Pakistan, but also Sri Lanka, actually got far less fuel. And that immediately had an impact upon their economy because there was not enough fuel for the production of their factories, but also cars and mobility.’ 

Narrator: We can't predict these shocks. Who would have thought a few years ago that Sri Lanka would be in trouble because of a war in Ukraine? 

Bruno Marchal: ‘Shocks that happen to us are one not predictable. What you can expect is that they will happen again, but you don't know which one.’ (55:08) ‘we'll have to have massive, massive, massive crises before we wake up. What kind of shock do we need to really wake up to the challenge of today? 

Narrator: It's one of the many questions Bruno is working on. How can we put systems in place, how can we prepare for complex problems that we don't even know are coming?  

Narrator: To answer that, we need to step into a car. 

SFX: Car doors open and close 

SFX: Sounds of car accelerating and driving, maneuvering 

Narrator: Imagine you're driving a car on a road you've never been on before. You don't know if there are potholes, unexpected structures, or detours ahead.  

SFX: Brake/shift gear noise  

Narrator: In this situation, you don't need a detailed map, a plan with every possible obstacle marked. What you need is a skilled driver and a well-maintained car with responsive brakes and steering. In other words, you need people and equipment with the capacity to respond quickly and effectively to any surprises you encounter along the way. 

SFX: Brake/shift noise

Narrator: Building capacity means making sure our systems are in place and our skills are sharp. For individuals as well as for organizations and governments. It's about giving ourselves and the rest of society the ability to deal with the unexpected, to be flexible and adaptive, even if we don’t know exactly what form the challenge will take.  

Bruno Marchal: ‘I heard some people talk about what we'll do now is prepare for 100 different kinds of crises, so that we have a crisis plan for each shock that will happen. Which is nonsensical and a waste of energy, because basically you don't know what will happen.(11:20) ‘Because what you see now is very much that we try to be prepared for the next COVID pandemic.’  

Narrator: From a crisis management perspective, that makes sense, but actually drawing a detailed plan is pretty pointless. We're nothing with a planned mega stock of face masks if the next disaster doesn't call for face masks. We're better off investing in an industry that can make other things besides masks. And preferably that industry is not on the other side of the world.  

Bruno Marchal: ‘Because we realized that all of the production was pulled back or kind of pushed out of the European continent to China. Well, if the Chinese factories are closed because of COVID, and suddenly you see, again, knock-on effects on the production chains and the distribution channels. It had immediate effects on how we could deal with the crisis.’  

Narrator: This global gap between where the protective materials were made and where they were needed made us less resilient. 

Narrator: To close the gaps in our resilience, we need competent people, people who want to rise to the occasion, who are motivated, who see the urgency. And that's exactly what we saw during the Covid crisis. 

Bruno Marchal: ‘General practitioners and community organizations and some other people start working together and they set up monitoring systems. They set up communication channels to communities that are hard to reach. They went to try to do contact tracing. And it's a good example of how in times of uncertainty, when in fact, at national or federal, Flemish, city level, there was not much direction yet, but still people do things.’  

Narrator: Such a reaction is only possible if the population has built up enough capacity to act and be flexible. 

Bruno Marchal: ‘It pushed us into almost a war economy. It's suddenly you saw that you close down all streets and all shops and I don't know, factories that used to make I don't know what, started now suddenly inventing respirators for hospitals. This massive mental shifts, mental model shift happened, and that created, I think again, the conditions for that kind of innovation and emergence.’ 

Narrator: When health care collapses, people and resilient health care workers are capital. 

Saleh Aljadeeah: Practitioners had to kind of be very, let's say, brave, you know. They do things they were not trained to do, you see?  

Narrator: We hear ITM researcher and pharmacist Saleh Aljadeeah, who we met in previous episodes and who experienced this firsthand during the war in Syria. 

Saleh Aljadeeah: I remember a colleague was telling me that they were involved in certain surgeries. They were not trained to do that, but they were told, okay, you are still better than a pharmacist. You are still better. I mean, better. You are more qualified to do that than a lab technician.’  

Narrator: Medical students also stepped in to do their part. 

Saleh Aljadeeah: ‘due to the conflict, also many people, many medical students could not finish their training. But still, they were very much involved in providing health care. Although per law, they were not qualified to do that. But still, again, they were told, okay, you are still more qualified than an electrician or an architect.’  

Narrator: Working in the midst of a crisis for five years, they acquired a unique skill set in dealing with emergencies and complex wounds. All with very limited resources. 

Saleh Aljadeeah: ‘So that's a very unique, I would say very unique qualification that practitioners could acquire there.’  

Narrator: Healthcare providers deserve more respect for what they do, agrees Lenka Benova, Professor of Reproductive and Maternal Health at ITM. Only when they get the right support and respect, will they continue to function in a crisis situation. 

Lenka Benova: ‘They are the software of all that is health system. And we often forget, neglect, their experience, their lived realities, and the way that they are asking to be supported in order to do their job well.’ 

Narrator: To better prepare for future crises, Lenka and her team wanted to understand how women's caregivers and more specifically midwives, coped with the pressure during the outbreak of the Covid pandemic. 

Lenka Benova: ‘And what the midwives were saying about what was happening around them and in their professional lives was incredible.’  

Narrator: In Belgium, midwives come to the home to support the mother in and after childbirth and to make sure everything is going well. When Covid arrived, everyone wanted gear to protect themselves. Gloves, aprons, masks. 

Lenka Benova: ‘And guess what? Midwives whose job it was to visit women at home postnatally were not prioritized for face masks. They were not considered among the list of essential workers. I mean, how much more essential does it get? How much more essential can you be than looking after babies who are days old and women who have just come home? Because we are so focused on populations, on patients, children, immunizations, supplies and equipment and money and money and money that we often forget to talk about health care workers other than in a way that blames or shames or names.’ 

Narrator: Even in the hospitals themselves, where everyone was seeing their work environment change dramatically, midwives were not asked for their opinions. 

Lenka Benova: ‘For example, one of the first rules that was implemented is a ban on visitors. No visitors, no family, and often no accompanying person. And banning birth companions, banning visitors for women who might have been hospitalized for weeks with some complications, women with premature babies in the hospital, was so against everything that midwives know about how to do their job well, that they actually went against the system. So the clinicians, the doctors, the managers imposed a ban on visitors. The midwives found a way to smuggle husbands into the kitchen to have five minutes with their wives once in a few weeks.  

Narrator: To an outsider, even during a crisis, everything may seem to run smoothly. 

Lenka Benova: ‘There are doctors, there are midwives, women give birth, women are discharged. But when you scratch the surface through a disruption like COVID, you see that midwives who are the front-line providers of respectful, normal, woman-centered care have very little voice in how systems, procedures, protocols, and clinical care is delivered. And that is not right.’ 

Narrator: You would hope we learn from the experience, that it won't happen again. But lessons are hard to learn. 

Lenka Benova: 'We are sick and tired of hearing about COVID to the extent that not even the lessons that had presented themselves on a golden platter are staying with us anymore because there is another priority, another thing to do, another policy to implement.'

Narrator: Overall, the Belgian system has the capacity to respond to crises. 

Bruno Marchal: ‘We were quite pessimistic about that, but some of the facts have proven us wrong. In fact, it is possible and it happens.’  

Narrator: But in Belgium it’s easy to talk. If you have ten general practitioners in a small community, some of them can take some additional measures and initiatives.  

Narrator: Compare that with countries where one doctor is responsible for an area of one hundred square kilometers. Under those circumstances you understand why new initiatives and responses to disasters are harder to start. Yet people do succeed. And the Global North can learn a great deal from the Global South.  

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Bruno Marchal: ‘Thailand has been exposed to a number of shocks over the last 15 years, from very severe political crisis to migration influxes from Myanmar to floodings and the tsunami, for example, to COVID-19.’  

Narrator: ITM is now working with local partners from the Chiangmai University to examine how Thailand has coped with this diverse set of disasters, how they learned from them, and how they are preparing for the next one. The key question is: 

Bruno Marchal: ‘One shock, the next one comes, what happens in between? How do they transform from one situation to the next?’  

Narrator: Responding to a disaster like a tsunami may involve traditional measures such as improving warning systems and building higher dikes. But addressing fundamental issues, such as reforming the insurance sector to speed up financial assistance, strengthens the ability of the entire system to respond to any crisis. Similar principles apply in other parts of the world, where interventions against flood risks can range from building dikes to educating people. With each level of intervention providing a stronger foundation, a better resilience than the one before.  

Narrator: And we might say that everyone is different, and that Thailand is not the same as any other country, and that's true. 

Bruno Marchal: ‘But cities are cities. We know that cities have properties. There are not 25,000 ways in which cities have evolved. There are patterns. We look for the patterns.’  

Narrator: Looking for patterns and learning from each other is something we need to do much more if we want to prepare for crises. As Lenka Benova points out 

Lenka Benova: ‘If we listen to each other, if we could say: ‘Hey, friends in Guinea, you've had an epidemic of Ebola. How did you figure out how to be able to take care of pregnant women at the same time where you had to minimize exposure of everyone to everyone else?’ But do you think we did that? I have yet to hear one policy maker or decision maker from a high-income country who consciously calls people in low resource settings who have much more experience with this and health systems sort of resilient with different shocks to ask for help or advice.’ 

Narrator: For that reason, ITM is participating in a study in Bamako, Mali, where a very resilient group of internally displaced people had to learn to cope with extreme changes as war, drought and climate change pushed them across the country. Still, they somehow find ways to survive. Hoping to learn from their stories, ITM researcher Houssynatou Sy went to her home country of Mali to talk to them and to study how this group of people tackles challenges. How do they remain resilient under these circumstances? It's an important question that the world can learn a lot from. And coming from Mali herself, she could read that situation much better than an outsider ever could. 

Narrator: Something that Saleh Aljadeeah, as a Syrian himself, also experienced when he did research with Syrian refugees in Germany. 

Saleh Aljadeeah: ‘I mean, refugees in the literature, in the research, or migrants are often described as a hard-to-reach group, you know. So when I started planning my PhD, this term had kind of a discouraging effect, you see, even like when I was interviewed by a funder, they were like, okay, are you aware that you are going into that kind of very difficult situation?’  

Narrator: Saleh planned to do a survey about health, intimate details, feelings. The expectation was that the group of refugees would turn away from Saleh and his survey wouldn't work. But Saleh persisted. And what did he find? Syrian refugees were not a difficult group at all. 

Saleh Aljadeeah: ‘I had really great time. Most of the patients were very open. They were actually very excited to talk about the issues they face. They say, oh, finally, somebody is asking us, how are you doing? You see? So actually, I've seen it the opposite. I found them more accessible. And I was asking myself if I have done a study with elderly population. I mean, this is a population I never worked with. I think I might have much more difficult time.’  

Narrator: When you're an outsider, it is much harder to help people become more resilient to shocks and crises. Is it even possible? How do you know what will work if you don't fully understand the culture? Prashanth Srinivas, who we already met in episodes one and two of this season and who works with an ethnic community in the forests of Southern India, knows all about this struggle. 

Prashanth Srinivas: ‘I think for me, the biggest challenge is that most people working with indigenous communities are not themselves indigenous people. So there aren't enough indigenous people who have been able to receive the kind of training in any discipline. So that's really at the heart of the challenge. That's the reason why there has always been others who have had to speak on behalf of these communities.’  

Narrator: If you always have to rely on outside people to find solutions for you, that quickly becomes problematic on many levels. 

Prashanth Srinivas: ‘Research has always then become something that others do, and I have to participate in it. I give data, and other English-speaking, educated people come. And that has to change.’  

Narrator: That's not how you build resilience. That’s not how you create people who can handle a crisis. 

Prashanth Srinivas: ‘for resilience and for dignity, public health has to put people at the heart.’  

Narrator: Knowing that we can’t prepare for everything, we have to build resilience to handle the crises of tomorrow and we have to learn from each other, from people who already lived the experience. Give people the chance to learn. And do it with respect. 

SFX: Egg sizzling in the pan 

SFX: Sip of coffee 

SFX: Sound of a newspaper being opened.  

Narrator: The newspaper is full of problems, priorities, disasters, and party politics. It is easy to lump them all together and decide that the challenge is too big to fight. Saleh experiences this every day. 

Saleh Aljadeeah: ‘I find it quite striking that when people, they ask me, what is your research on? I say: on access to medicines in conflict zones, I focus on northern Syria. So many people react, oh, is there still conflict in northern Syria?’ 

Narrator: The conflict in northern Syria has been going on for many years and has become chronic. People no longer see chronic conflicts as a disaster or an emergency. It isn’t news anymore. 

Saleh Aljadeeah: ‘If there is a bomb now in northern Syria, what is new about this? You see, this will become the case if hopefully not the conflict would go on in Ukraine.’  

Narrator: At some point, we normalize conflict and human suffering in these regions. And that has a tremendous impact on health care. 

Saleh Aljadeeah: ‘And this should not be the case. I don't know, how can we be aware, raise awareness about the human suffering in these settings? But what I see that these countries get off the radar. So this is quite challenging. I think it's quite challenging for also researchers who want to convince funders to look at these settings.’ 

Narrator: Never normalize a crisis. Never give up. We need to keep our eyes on the never-ending quest for a healthier world for everyone. Or as Lenka would say: wake up angry every day. 

Lenka Benova: ‘Yeah, you get exasperated at times, but I think it's a positive kind of anger. It's the anger that drives you to do your best. It's not every day a frustrated anger.’ 

Narrator: Think about the black box we opened in the first episode of this season. It was a box that contained the whole system needed to keep us healthy. It contained plans, strategies, people and buildings. Looking at it from the outside, the system hums on a daily basis and seems sturdy, but the researchers at ITM look at the system with curiosity. They want to understand how it works, how to make it work better and how to make sure it doesn't collapse at the first disaster. 

Saleh Aljadeeah: I think we should remember that access to health care is a basic human right. This is not a luxury. This should not be a case to put pressure on population. Nobody should suffer because of lacking access to medicines due to political decision you see...this is immoral.’ 

Narrator: So ITM researchers keep on exploring. Together with their partners, they know that our health care systems cannot be taken for granted. And we hope that now, you know this as well.  

Narrator: Thanks for listening. If you enjoyed these episodes, make sure to check out the first season of Transmission, devoted to outbreaks. From early encounters with Ebola in distant villages to the recent fight against COVID-19 in bustling urban settings: the four episodes of the season tell tales of resilience, discovery and humanity under the most challenging circumstances imaginable. And stick around for the third season where we’ll look at disease elimination. Because, wouldn’t the world be a better place if we just got rid of all those diseases? For more information about the Institute of Tropical Medicine in Antwerp, visit ITG.be/podcast.