Category Archives: The Partners in Health Model: Vision and Expansion

The Partners in Health Model: Vision and Expansion

Partners in Health and Promoting Community Development

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Partners In Health has often been discussed as the NGO that has one of the most successful models, but by looking at its shortcomings it paints a more realistic picture of the challenges in delivering health to peoples in developing worlds. Seeing its development and its efforts to expand demonstrate the moral obligation many feel towards providing adequate healthcare to all people, despite the dangers and unanticipated consequences as seen in their intervention in Sierra Leone.
Drawing back to the three core principles of Belmont Report, PIH has been successful in giving back dignity to impoverished people. Instead of focusing solely on the “zoe,” which groups like MSF are only equipped to do, PIH attempts to make humanizing people a goal. This is why I found the events in Ebola particularly shocking in regards to the Sierra Leone health worker. Health workers contracting a disease is probably one of the most feared unanticipated consequences of global health interventions. Out of the two health workers who contracted ebola, the one from Sierra Leone faced the most difficulty in being transported to a proper facility. Shouldn’t there be a moral obligation to protect health workers whether or not they are the “white savior” or a member of the local population. This brings up a question of valuing one life over another. Is the life of a foreign NGO worker more valuable than a community volunteer?
PIH has been greatly successful in delivering AIDS and tuberculosis treatment in Haiti and Rwanda, which is by no means a small feat, so its understandable why many other NGO’s would follow their model. By focusing closely on partnerships with the community, PIH manages to develop more effective treatment plans that combat low retention rates produced by structural violence. Both Zanmi Lasante in Haiti and Inshuti Mu Buzima in Rwanda demonstrate PIH success at forging community partnerships and the effectiveness of adding horizontal measures to improve vertical approaches. By giving incentives like food and transportation they improve the quality of life for people while at the same time serving more people. By removing some barriers caused by structural violence more people are able to in treatment longer.
While it’s nice to think that Paul Farmer has all facets of global health figured out, when looking at PIH’s ebola intervention there are issues in their approach. It brings into question why their model works in some cases but not in others. It’s necessary to develop programs “that are appropriate to the needs of the population” (Farmer 217). What differences are there in treating HIV/tuberculosis and ebola? How should PIH adapt their model to successfully treat ebola safely? In Haiti, PIH was able to forge strong community partnerships and train local people to be health workers which is an approach that successfully integrates the community into their intervention and gets them invested in the future. It allows for some growth in the health care system. For example after the 2010 earthquake in Haiti, Haitian doctors and nurses that were supported by PIH were able to respond to the disaster (WGBH). Vanessa Kerry, the CEO of Seed Global Health tries to implement PIH’s model and seeks to train skilled doctors and nurses in Haiti. In an interview she describes how 42 Americans were able to train more than 4,000 medical professionals in Africa. The PIH model realizes the need for extensive follow-ups that go beyond the immediate crises that organizations like MSF deal with, however this seems problematic in areas in immediate crisis. How can PIH hope to make long lasting change in more dangerous situations like Sierra Leone?

Discussion Questions:
What approach should have Partners In Health should have taken in Sierra Leone? What are possible unanticipated consequences?
How can PIH form equal partnerships with governments and have effective leadership in their interventions?

Sources:
Farmer, Infections and Inequalities, Ch. 8
Farmer et al textbook, Ch. 6
Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” New York Times 12 Apr. 2015: n. pag. Print.
Ross, Elizabeth “Beyond Ebola: Boston Physicians Lead Global Effort To Prevent The Next Pandemic” WGBH News 28 Oct. 2015

The Partners in Health Model: Vision and Expansion

Institutional Support?

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Before looking more closely at the Partners in Health (PIH) model, we analyzed the impact of NGOs. While most NGOs are able to provide temporary relief to individuals in a population, they often fail at creating sustainable infrastructure to address broader issues affecting a whole population. One example of an NGO, however, that has been rather successful in creating structural-based changes has been PIH. Although we’ve mostly been following PIH’s work in Haiti, the organization’s involvement in Rwanda has also led to promising changes in healthcare delivery there (4). PIH can’t take all of the credit though. Rather, their partnership with the Rwandan Ministry of Health (5) as well as with their well-endowed affiliated institution, Harvard University, has been crucial to their continued success. Harvard Medical School, along with its affiliated medical centers like Brigham and Women’s Hospital, has especially been able to supply much of the initial resources and expertise necessary for this endeavor (4). Corrado Cancedda uses the work of Harvard as a guide for other U.S. institutions on how to “channel the innovation, creativity, resources, and expertise of academia toward the pursuit of global health inequity” (4). Institutions no doubt can play an important role, yet with the exception of other institutions in the Ivy League and perhaps Stanford, I wonder how reliably PIH’s institutional model applies to less-endowed U.S. institutions.

Many institutions have already been aiding in the Global Health effort. Brown’s Global Health Initiative, for example, provides scholarships to students seeking to conduct relevant projects or research in other countries, just as it encourages collaboration with institutions in other countries. The Alpert Medical School even has some collaboration with St. Damien Hospital in Tabarre, Haiti (2), yet there haven’t been updates regarding this collaboration since 2010 (1). For the most part, Brown’s position in the Global Health effort mainly takes the form of research, as do other institutions. Case in point, the most recent global health related article published by Brown discussed research done on HIV incidence in Nigeria (3). Harvard University certainly pioneered a different approach to institutional involvement, one that partnered with an NGO founded by two of its alumni and the Ministry of Health of Rwanda in attempt to change the way healthcare was delivered there. With one of the highest U.S. institutional endowments, some of the brightest educators and doctors, and some of the top medical and research centers in the world, Harvard is no doubt an institution that can afford to go to these great lengths and do so well. Its financial and research position allows it to wield great power and influence over systemic changes in other countries. In the case of other institutions that have fewer resources, money, and prestige, it seems they would be less likely to get past the “NGO state” when conducting global health projects, i.e. providing temporary fixes as opposed to broad, structural-based changes. This is not to discredit the global health work other institutions do and have been doing, but this is to question how replicable the PIH partnership model is for other institutions.

Discussion Questions:

1. How can the PIH partnership model apply to other less-endowed institutions?

2.  What are some other ways these institutions can create broad, structural-based changes in other countries?

Cited

  1. Brown University (2015) Global Health Initiative: Alpert Medical School in Haiti. Retrieved from http://www.brown.edu/initiatives/global-health/haiti/alpert-medical-school-haiti
  2. Brown University (2015) Global Health Initiative: Medical Education and Leadership Development. Retrieved from http://www.brown.edu/initiatives/global-health/haiti/medical-education-and-leadership-development-project-meld
  3. Brown University (2015) News From Brown: HIV Spreads Faster as Violent Conflict Looms. Retrieved from https://news.brown.edu/articles/2015/11/hivwar
  4. Cancedda, C., Farmer, P.E., Kyamanywa, P. (2014). Enhancing Formal Education and In-Service Training Programs in Rural Rwanda: A Partnership Among the Public Sector, a Nongovernmental Organization, and Academia. Academic Medicine, 89 (8), 1117-1123.
  5. Farmer, P.E., Kim, J.Y., Kleinman, A. (2013). Reimagining Global Health: An Introduction. (172-182). Berkeley and Los Angeles: University of California Press.
The Partners in Health Model: Vision and Expansion

Partners in Health Creating Systems for Years to Come

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This will become very clear throughout this blog post, but I believe Partners In Health is a wonderful organization that has made a positive impact on the lives of millions of people across the world. Nongovernmental organizations, such as PIH, take responsibility for what many local governments either cannot or will not allocate time and money towards; the health of their nation. These organizations commit to a goal of improving the health of hundreds of thousands of people, with a genuine desire to help.

The focus of Partners in Health in the case of Rwanda was to develop a sustainable health system in a nation that desperately needed sanitary facilities to properly care for infectious diseases. This summer, I worked with the Uganda Village Project in rural Uganda to collect water and sanitation data, increase access to clean water sources and hygiene and sanitation workshops. During my time living and working with the villagers of Kasambiika, I learned that education was the most valuable tool we could offer them. For example, the team who lived and worked in Kasambiika the summer of 2014 built tippy taps, a hand-washing station made of household items, for the local primary school. However, less than a year later, the parts of these tippy taps were stolen or broken, and no one knew how to put them back together. This year we held a workshop to education the children and staff on how to build a tippy tap and the importance of sanitation. This enabled the community to repair or rebuild these structures if necessary.

In this line of work, nongovernmental organizations come out of nowhere to an established community and impose change. For the most part, good change. However, change, no matter how positive or negative it is, is sometimes hard to accept. At the end of it all, these organizations then pack up all their things and leave the community, wishing the best for them. What PIH does well in Rwanda is the educational program with Harvard Medical School and Brigham and Women’s Hospital. This partnership “helped the Rwanda MOH and academic institutions establish new or strengthen existing formal educational programs (conferring advanced degrees) and in-service training programs” (Cancedda) with local health workers. Training local community members presents new opportunities for individual and autonomy for the health of the community. This partnership lessens the dependence on the NGO in the long term and increases the overall health of the community, even after PIH leaves.

Again, this model of health work in nations with high rates of communicable diseases and other health burdens has contributed a lot of positive change in the world. That is not to say, however, that this is a flawless model. First, the level of dependency Partners in Health has on its donors is not sustainable or completely reliable. Further, the person or company that is donating the money will more or less have a say in where the funds are allocated. Speaking of sustainability, foreign NGOs, no matter now noble the cause, will always be foreign to the communities they are trying to help. This runs the risk of imposing foreign notions or practices without considering local cultures.

 

 

 

Discussion Questions:

 

What are some ways that nongovernmental organizations, such as Partners in Health, can find more stable, consistent funding and rely less on donations?

 

How could Partners in Health offer more sustainable interventions; further, what are some unforeseen consequences of their work?

 

Sources:

  • Farmer, Infections and Inequalities, Ch. 8
  • Farmer et al textbook, Ch. 6
  • Cancedda, Corrado et al. 2014. “Enhancing Formal Educational and In-Service Training Programs in Rural Rwanda: A Partnership Among the Public Sector, a Nongovernmental Organization, and Academia” Academic Medicine 89(8): 1117-1124.

Fink, Sheri. 2015. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times April 12.

The Partners in Health Model: Vision and Expansion

Treatment IS Prevention: How PIH Reconstructs What Is Good

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A recurrent theme in this course has been that programs in international health need to address the root causes of disease, as well as the biosocial contexts in which these diseases arise, in order to achieve some success (Lecture 1). Paul Farmer and his model of Partners in Health support this idea, creating programs that take into account the poverty, structural barriers, and social norms that often determine who benefits from health care systems and who doesn’t (Farmer et al. 4). What I find interesting, however, is that Farmer argues that development efforts seeking to address these issues should not necessarily be prioritized over the treatment of patients in immediate need (Farmer 217). I would like to look at whether this argument is made on a fundamentally moral basis (as in we have “the moral responsibility” to treat suffering patients) or effectiveness basis (treatment is good in the long run and reinforces development goals).

I think that PIH programs directed at tuberculosis are a good place to start, as TB is a disease that is not only intertwined in the issues of poverty, but also in debates about non-compliance and cost-effectiveness. Furthermore, although cures exist, TB continues to exact an enormous toll on populations and is projected to be the cause of 30 million more deaths by 2020 (Farmer 212). Because there are so many people suffering now and so many people expected to be suffering in the future, I think there is already a contradiction in where the money should go: Should funds go towards antibiotics to cure the people suffering right now? Or would the funds be better served in long-term infrastructure improvements, such as clean water systems, that will improve overall health and prevent future TB cases?

I believe that Paul Farmer’s answer, by the way he structures PIH, is both-that there shouldn’t be an “either-or” scenario (Farmer 217). For one, the effectiveness of financial assistance, nutritional supplements, and follow-up visits (Farmer 219) may refute the idea of cost-effectiveness. The accompaniment method of PIH is far less expensive than paying for the hospitalization of the patients if they are unable to comply (Farmer 224), which is often the case if antibiotics are distributed without accompanying social programs.

In terms of whether money should be going to development or treatment interventions, I think that Farmer is correct in saying that treatment is often prevention. An effective biosocial approach will cure patients, halt the progress of MDR TB, and prevent transmission; furthermore, “individuals with active pulmonary disease are most likely to transmit the disease to others” (Farmer 225). In other words, the treatment of those who suffer most is also the most effective way to prevent transmission. In this way, I think the effectiveness rationale reinforces the moral responsibility. Farmers argument conveniently aligns the interest in patients suffering now with concerns in the future.

One of the things that has interested me throughout this course is how interventions are based on social constructions of good, more specifically the often opposing ideals of the common good versus the good of the individual. We have seen in many instances how treatments that save individuals do little to nothing to the population, and that interventions designed to significantly ameliorate health in the population may neglect the well-being of minorities (Lecture 2). I think that, while Farmer’s model of PIH does not solve this problem, the aligning of development in population with care for individuals does shed some important light on how we should create programs in trying to impact the most “good:” utilitarian notions of cost-effectiveness in affecting good are automatically limited by perceived limitations of what is possible. When we reconsider constructions of what is possible, and aspire to care of any kind for individuals in poor places, we are more than often surprised by what programs can do.

Discussion Questions:

  1. In Sierra Leone, there is an attempt by PIH to use the resources for the treatment of Ebola patients to build a sustainable health system (Fink). Yet this leads to unintended consequences, when the government of Sierra Leone, which is supposed to maintain the health clinics, fails to provide safe equipment and two PIH volunteers contract Ebola. Are there any other ways in which the alignment of vertical and horizontal, treatment and development, can have negative consequences?
  2. Although Farmer makes a convincing argument that both treatment and development are important, there is still a question as to how much resources should be devoted to one and how much to the other. Should building infrastructure and treating patients be valued equally, or is one ultimately more important than the other?
  3. How would you define and measure making “good”? Do the numbers matter?

Sources:

  • Mason, Katherine. “Lecture 1.” Providence. 09 Sept. 2015. Lecture.
  • Mason, Katherine. “Lecture 2.” Providence. 11 Sept. 2015. Lecture.
  • Farmer, Paul. Infections and Inequalities: The Modern Plagues. Berkeley: U of California, 1999. Print.
  • Farmer, Paul, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico. Reimagining Global Health: An Introduction. N.p.: n.p., n.d. Print.
  • Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” New York Times 12 Apr. 2015: n. pag. Print.
Section 3, The Partners in Health Model: Vision and Expansion

Exceptional Treatment of Global Health Workers

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The outcomes of Partners in Health’s (PIH’s) previous interventions imply that partnerships with community health leaders play a critical role in the success of global health programs. While these leaders are invaluable, their lives are not treated as such, especially when compared to the lives of foreign aid workers. This discrepancy indicates a rooted hierarchical structure in foreign aid groups – even in ones like PIH that recognize the necessity of collaborating with individuals who belong to the communities that are receiving aid.

PIH’s health care delivery model factors in the requisite of fostering and relying on community partnerships. This component has proven to be a critical contributor to PIH’s global health programs, which focus on combining horizontal and vertical care by integrating aggressive infectious disease treatment and structural reformation. (1) For example, PIH’s ‘Proje Veye Sante’ largely relied on “accompagnateurs,” or paid community health workers, to “interface between the clinic and the community.” (2, 3) As shown by the project’s outcomes, the success of health interventions is contingent on decreasing structural barriers through various services (e.g. provision of food, transportation, etc.) and, accordingly, on the participation of community health leaders who conduct these services. (4)

In a sense, the community members’ roles in PIH’s efforts illustrate their resilience and leadership in the face of inequality and structural violence. Rather than the community depending exclusively on an NGO to work for them, the NGO instead relies on the community in order to make a sustainable impact. This interdependent relationship also draws attention to PIH necessarily collaborating with community members to augment its biosocial view and to better understand how to meet local needs. This is seen in the story of Haitian Catholic priest and psychologist Père Eddy, who has served as director of Zanmi Lasante’s (as PIH is known in Haiti) mental health program since 2005. (5) Zanmi Lasante’s HIV and tuberculosis program recruited Père Eddy, a past counselor for sexually abused teenagers and for victims of post-traumatic stress after 2004’s coup d’etat, in order to provide better assistance to patients who were dealing with depression, psychosis, social isolation, and stigma. (6) There, he “trained social workers how to meet their patients’ psychological needs.” (7) He understood so well his community/community-based work that his methods “were later used by PIH community health workers in settlements for displaced people and were adopted by the Haitian government to help mourners nationwide.” (8) Overall, Père Eddy’s background not only as a psychologist and pastor, but also as a Haitian citizen who has experienced social inequalities and violence first-hand, provides him with a more appropriate skill-set for delivering care to the population of interest and for educating PIH volunteers.

While local health workers ostensibly play just as valuable a role in PIH’s outcomes as PIH volunteers (professionals, logisticians, etc.) do, their lives are less valued than their foreign partners’. When an American PIH volunteer in Sierra Leone contracted Ebola, he was quickly transferred to the United States for treatment. (9) The same level of care was not provided for native community health leaders: Usman Mohamed Koroma, “a ministry employee who helped oversee infection prevention and control at the site,” contracted Ebola the same week but had to wait two days before being moved to Sierra Leone’s “British-run treatment unit set up for sick health workers.” (10) Thus, despite being colleagues both essential for PIH’s work, “one [received] arguably the best Ebola care in the world [while] the other [received] the best Ebola care available in one of the poorest countries in the world.” (11)

Why, in an organization like PIH that identifies the importance of community health advocates, is there preferential health treatment for foreigners? There are potentially several factors that contribute to this disparity. Nevertheless, this situation highlights the inherent hierarchial structure of foreign aid: the best treatment is reserved for those who hold the most power – for those who, driven by morality but under no obligation, have entered and brought resources to a foreign country. On the other hand, community health leaders, who belong to the population that is receiving aid, often derive the opportunity to showcase their agency from the foundation laid by global health organizations. They are therefore seen (and treated) as lower in the hierarchal configuration; their ability to help their communities necessitates the foreign aid organization being present — not because they have no agency, but because the structural inequalities they face obstruct their agency. Only when organizations like PIH are present to diminish fundamental inequalities — by providing financial assistance and resources — are community health leaders able to further help their fellow citizens. Perhaps, though, despite PIH’s attempts to decrease structural violence by meeting basic and financial needs, the underlying inequalities of the community they are attempting to improve pervades and is reflected by their work.

Update:

Hi Everyone,

This is an update to my blog post based on the discussions that were presented in the comment section. Before I address some of my new thoughts/conclusions, I want to clarify my opinion on PIH. I think that PIH executes great work; its model (described in the readings) is quite effective, and the administrators/members have designed effective methods in order to create large impacts on communities that need aid. Furthermore, I believe that PIH does work under the idea that all lives are equal; in fact, as we discussed in class, PIH is perhaps designed to provide a preferential option for the poor (i.e. they seek to act on inequality). My blog, therefore, was not meant to completely condemn PIH and render it hypocritical/discriminatory but rather to present a concern I have about PIH’s limitations. While PIH may want to provide equal care for all of its members (Fink’s article did indicate that PIH volunteers tried to negotiate and make several calls in order to get Usman Koroma the help he needed), they are sometimes unable to. Why is this? This is one of the questions I was trying to address, and I originally proposed the inherent hierarchal nature of NGO work as a potential answer.

I’ve thought a lot about this question since, and I have some new ideas that I’d like to share. I think that the resource-poor setting in which NGO takes place plays a large role in the preferential treatment to foreign aid workers. NGOs like PIH may emphasize this idea of ‘getting funds if you need them,’ but realistically, there are financial limitations that prevent everyone from getting access to equal care. (If there weren’t financial limitations, why wouldn’t PIH try to fly every sick person to a country with better health services?) These financial – and logistical – limitations become even more visible in the event of an emergency like the spread of ebola to volunteers. (I’m using the word ‘emergency’ in a specific way right now, but I do acknowledge that it’s difficult to define what exactly an ‘emergency’ is.) Therefore, NGOs have to make a decision about how to distribute their resources. And after more thought, I have identified three main factors that contribute to an NGO’s hierarchy and that influence an NGO’s decisions regarding allocation: 1) Place of Origin, 2) Academic Credentials/Expertise (I’m combining the two, though you identified them separately), and 3) Sphere of Influence (how much influence they have in a community — though this is hard to measure). Regarding the first point, I am assuming that foreigners are often the wealthier players in this situation; they are the people bringing resources into a country that lacks them. As for the second point, while all members (at all levels) are important to NGO work, I think it’s important to consider whether an NGO’s foundation in another country (infrastructure, health centers, logistics, etc.) would exist without the involvement of professionals.

Now that I’ve discussed more potential causes of preferential treatment, I want to focus on two of the questions I asked: Is it possible to eliminate the inherent hierarchical structure of global health organizations? Our classmates had varying opinions on this. Some argued that eliminating the hierarchy is possible. Yuki commented that NGO workers should place more value on the views of community members before doing their work to ensure that community health workers are valued as equal colleagues. Sara also shared a hope of eliminating the hierarchy. Methma, on the other hand, suggested that hierarchy is the nature of health care work and therefore cannot exactly be eliminated. I agreed with this but suggested that maybe some steps could be taken to reduce consequential inequalities of the hierarchy: perhaps instead of trying to completely dismantle the hierarchy, NGOs could give community health leaders higher positions within the hierarchy. By including them in decision-making processes and providing them with actual statuses, an NGO could possibly use its inherent hierarchy to further highlight the agency of the community. Another commenter, Niki, suggested that perhaps the problem we should focus on isn’t the hierarchy but rather safety regulations in general. After all, the lack of safety is what led to PIH’s volunteers contracting ebola in the first place. And I think Niki’s point raises yet another important idea to contemplate: as I stated in a comment, PIH strives to collaborate with governmental bodies/institutions (e.g. Sierra Leone health ministry) in an attempt to make health interventions more sustainable. This means that, unlike groups like Doctors Without Borders, PIH relies on the local government for protective gear and supplies. This obviously becomes a problem when safety lapses (e.g. faulty gear) occur because resources are less regulated. Although involving the government and making use of local resources may be critical to PIH creating self-sustaining health infrastructure, it seems like it also can be quite harmful (depending on the government’s capabilities).

Overall, maybe there is a way to abolish the hierarchy, but maybe there isn’t. Maybe we should direct our concern elsewhere. Clearly, this topic/debate is extremely multifaceted, but I hope that this blog and its comments have encouraged you to think about new ideas.

Footnotes

  1. Drobac, Peter, Matthew Basilico, Luke Messa, David Walton, and Paul Farmer. Reimagining Global Health. (Berkeley and Los Angeles: The Regents of the University of California, 2013), 133-183.
  2. Ibid, 160
  3. Farmer, Paul. Infections and Inequalities. (Berkeley: University of California Press, 1999), 211-227.
  4. Ibid
  5. “Père Eddy, Haiti’s Patron Saint of Mental Health.” Partners in Health. October 22, 2015. http://www.pih.org/blog/pere-eddy-haitis-patron-saint-of-mental-health
  6. Ibid
  7. Ibid
  8. Ibid
  9. Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times, April 12, 2015.
  10. Ibid
  11. Huster, Karin, All Lives Matter, Slate, April 6, 2015. http://www.slate.com/articles/health_and_science/medical_examiner/2015/04/ebola_treatment_in_sierra_leone_and_united_states_who_decides_where_doctors.html

Bibliography

Drobac, Peter, Matthew Basilico, Luke Messa, David Walton, and Paul Farmer. Reimagining Global Health. Berkeley and Los Angeles: The Regents of the University of California, 2013.

Farmer, Paul. Infections and Inequalities. Berkeley: University of California Press, 1999.

Fink, Sheri. “Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak.” The New York Times. April 12, 2015.

Huster, Karin. “All Lives Matter.” Slate. April 6, 2015. http://www.slate.com/articles/health_and_science/medical_examiner/2015/04/ebola_treatment_in_sierra_leone_and_united_states_who_decides_where_doctors.html

“Père Eddy, Haiti’s Patron Saint of Mental Health.” Partners in Health. October 22, 2015. http://www.pih.org/blog/pere-eddy-haitis-patron-saint-of-mental-health

 

Discussion Questions

  • Who are more necessary, community health leaders or foreign volunteers/aid groups? Should both types of volunteers receive the same healthcare? If yes, should all members of the community also have equivalent access?
  • Is it possible to eliminate the inherent hierarchical structure of global health organizations? Is doing so necessary?
  • What factors contribute to the preferential treatment of foreign aid workers?

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