Health, famously defined by the WHO as “a state of complete physical, mental and social well being” [1], is arguably one of the most fundamental entitlements of life. Tragically for millions of people around the globe this basic right is not realised due to lack of access to health care, a fundamental determinant of health in a population through its roles in preventing and treating illness and promoting good health practices.

Fractured health care

Disparities in health care availability, access and quality are entrenched internationally between developed and developing nations as well as within countries, both between urban and rural regions and affluent and poorer areas. Thus from the outset of life, in terms of health outcomes, where you live matters. In London, a baby born today would expect to survive to the grand old age of 80. Compare this to Malawi, one of the poorest nations in the world, where the average life expectancy at birth is just 50 years [2].

The distorted allocation of human capital to deliver heath care services is one situation which fuels these gross inequities in health outcomes. Malawi has a huge deficit in health care professionals, with less than one doctor per 10,000 citizens [3]. Despite the fact that only 18% of the population reside in urban areas [4], a disproportionate number of doctors work at central referral hospitals in these regions. Consequently, some district hospitals serving rural populations do not employ a single doctor. This leaves medical assistants, nurses and clinical officers (akin to specialist nurse practitioners in the UK) to provide the medical care [5].

This fractured state of heath provision in Malawi is further exacerbated due to acute shortages of specialists in many areas within the medical profession itself. This includes orthopaedic surgeons of which there are only nine to serve the entire population [6]. With the huge focus on communicable diseases such as HIV/AIDS in the developing world, it is easy to forget the significant contribution of musculoskeletal conditions to morbidity and mortality in these countries. Although this burden is not well documented in Malawi, the fact that motor vehicle accidents are the eighth commonest cause of death amongst adults [7] argues for increased resource allocation to the orthopaedic specialty.

Local solutions – the Orthopaedic Clinical Officer

The desperate state of orthopaedic care in Malawi was observed by Dr Edward Blair whilst working as a Rotary International volunteer orthopaedic surgeon in the mid 1980s. At the time Malawi was completely reliant on expatriates, having no orthopaedic specialists of its own. Compelled to improve the situation, he developed an 18 month programme to educate existing clinical officers to manage common orthopaedic problems, reserving the expertise of orthopaedic surgeons for more serious cases. The significantly lower input costs and training time in comparison to full orthopaedic surgical education enabled the rapid deployment of specially trained paramedical professionals, now known as Orthopaedic Clinical Officers (OCOs), to expand orthopaedic facilities, particularly in rural areas [6].

Professor Chris Lavy restarted the course in 1990s after it had fallen into financial hardship, obtaining funding from the United Kingdom Department for International Development and the Nuffield Foundation through THET (Tropical Health Education Trust). He says of the OCOs, “They are great at what they can do, which is the delivery of conservative care to people with common fractures and dislocations. These common conditions make up the vast majority of injuries that present at district hospitals in Malawi.” The OCO impact on access to orthopaedic care has been remarkable. Collectively, by the mid 1990s actively practicing OCOs were seeing approximately 150,000 patients per year, the majority of diagnoses being trauma related. Furthermore, with over 50% employed by District and Mission Hospitals, this goes some way to fill the void of musculoskeletal expertise in rural areas [6].

An additional advantage of the scheme has been that the OCO profession has not been subject to the migratory ‘brain drain’ that occurs in other healthcare sectors, with all practicing OCOs still working within the county [6]. The exodus of healthcare workers out of Malawi to nations with stronger economic prospects has been particularly damaging to the nursing and midwifery pool, with over 100 personnel per year emigrating to countries such as the UK. This exacerbates an already critical situation, where over 60% of nursing posts are vacant nationally [5]. As their qualification is not recognised outside Malawi the OCO specialty triumphs by being exempt from this phenomenon, which keeps indispensible frontline healthcare staff in the country and means the investment in their training is fully realised.

Looking to the future

Currently the programme has an annual intake of 10-15 students per year but because OCOs will continue to be the key deliverers of primary orthopaedic care for the foreseeable future, the need for expansion remains [6]. Of course this is dependent on the concomitant amplification of financial backing which has changed in recent years, when income from its major donor THET ended in 2007 [6]. Alternative sources have had to be sought to allow training to continue as Stuart Palmer, the current course director in Malawi, explains. “The Ministry of Health is now on board here in Malawi as a core funder for the course but we still need to keep working with them and others to see it grow further.” The dependence on external bodies for the support of the course highlights the need for continued awareness, both inside and outside Malawi, of the importance of the multifaceted benefits OCOs deliver to ensure that care of musculoskeletal conditions is not put on the back-burner. 

Despite the apparent successes of the scheme it is important to recognise the limitations of the care that can be provided by OCOs. Their role is no replacement for the expertise of orthopaedic surgeons that is required to manage more complex presentations. Current postgraduate arrangements aim to produce between one and three graduate orthopaedic specialist doctors per year but an escalation in training places will be required to produce enough surgeons for equitable nationwide coverage [6]. The existence of OCOs should not detract from the need to train more orthopaedic surgeons.

As shown by the success of the OCO course in Malawi, it is possible for low cost programmes utilising existing paramedical professionals to rapidly meet the needs of side-lined specialties such as orthopaedics. Stakeholders in public health in developing countries need to recognise the potential of such interventions as an important tool in redressing the gross urban-rural inequity in healthcare access that prevents so many from receiving the care that they deserve.

Tamsin Cargill

4th Year Medical Student, Imperial College London

tnc06(a)ic.ac.uk

 References 

1. Constitution of the World Health Organization. Basic Documents, Forty-fifth edition, Supplement, October 2006. World Health Organization Web site. Available at: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf Accessed: June 2010

 2. WHO World Health Statistics Report 2009. World Health Organization Web site. Available at: http://www.who.int/whosis/whostat/EN_WHS09_Table1.pdf Accessed: November 2009

 3. World Health Statistics Report 2009. World Health Organization Web site. Available at: http://www.who.int/whosis/whostat/EN_WHS09_Table6.pdf Accessed: November 2009

 4. World Health Statistics Report 2009. World Health Organization Web site. http://www.who.int/whosis/whostat/EN_WHS09_Table9.pdf Accessed: November 2009

 5. Record, R., & Mohiddin, A. (2006). An economic perspective on Malawi’s medical “brain drain”. Globalization and Health, 2, 12.

6. Mkandawire, N., Ngulube, C., & Lavy, C. (2008). Orthopaedic clinical officer program in malawi: A model for providing orthopaedic care. Clinical Orthopaedics and Related Research, 466(10), 2385.

7. WHO Country Health System Fact Sheet 2006 – Malawi. World Health Organization Web site. Available at: http://www.who.int/whosis/mort/profiles/mort_afro_mwi_malawi.pdf Accessed: November 2009

By Carlos Fioravanti

State University of Campinas

chfioravanti(a)gmail.com

A versatile new drug candidate called P-Mapa along with a new proposal to fight infectious diseases have emerged in Brazil. They are the result of collaboration among non-academic and academic groups in Brazil, Chile and the US led by the non-profit research network Farmabrasilis.

Figure 1. Crystals (300 x) and nanocrystals (37,000 and 80,000 x) of P-Mapa: an immunomodulator derived from Aspergillus orizae  (Credit: Courtesy Farmabrasilis)

P-Mapa, a proteinaceous aggregate of ammonium and magnesium phospholinoleate-palmitoleate anhydride, is a biotechnological compound derived from Aspergillus orizae [1]. It is an immunomodulator, which can rebuild the organism’s natural defence system against tumours, viruses, bacteria and other disease-causing microbes.

P-Mapa has demonstrated anti-tumor activity, with no relevant signs of toxicity, on studies performed on rodents, non-human primates and on HIV-positive patients-phase I clinical trial [2,3,4]. The compound was shown to induce proliferation of lymphocyte T, increase cytokine production and natural killer cell activity, and stimulate nitric oxide release by macrophages [5,6,7].

Scientists from the Brazil-based Farmabrasilis and the US National Institute of Allergy and Infectious Diseases (NIAID) have confirmed the potential of P-Mapa to treat infectious diseases. In 2009, Farmabrasilis and NIAID teams showed that P-Mapa can protect against Punta Toro Virus (PTV), which produces a fatal hepatic disease in animals and is closely related to the Rift Valley fever virus, endemic in sub-Saharan Africa. In these experiments P-MAPA was compared to the antiviral Ribavirin. Both were able to protect 100% of all infected animals with no signs of hepatic damage, strengthening the possibility of using P-Mapa as adjuvant to treat hepatitis B and C, mainly when the first-choice medicine has limited use or with adverse effects [7,8].

The latest tests carried out by Brazilian and American teams have demonstrated that P-Mapa is active against Mycobacterium tuberculosis in vivo. Wild-type C57BL/6 mice were exposed to an aerosol of M. tuberculosis and later treated with P-Mapa and the antimicrobial Moxifloxacin, used both alone and together. The P-Mapa acted alone to deter the bacterial proliferation in the lung and spleen at levels above the minimum standards required. P-Mapa may have synergized with Moxifloxacin, as the combination of the two drugs provide wider protection than each when used alone [9].

A plan to fight infectious diseases

Based on these data, the Farmabrasilis team proposed the use of P-Mapa to fight infectious diseases. Launched in 2009 at 3^rd Stop TB Partners Forum, the proposal focuses on the re-establishment of the patients’ natural defenses (immunocompetence) by using P-Mapa as an adjuvant medicine with antiviral and antimicrobial drugs. This approach could help to prevent or treat diseases such as tuberculosis and malaria in patients, including those co-infected with HIV.

The Farmabrasilis proposal includes the possibility of sharing all data and methods of production, free of charge, with governments, institutions or groups interested in using the P-Mapa to treat neglected diseases and disadvantaged populations. In such cases, partners cannot sell the medicines or the technologies associated with them, and must also offer the medicine free of charge to people who most need them, as detailed on the Farmabrasilis website [10].

Broader than other approaches from other Public-Private Partnerships, Farmabrasilis’ call for a collective, open task force against infectious diseases represents a way to reduce the cost of drug development whilst engaging civil society organizations in the search for new models of medicine research and production [11,12].

A collective effort

In its use of non-academic and academic groups, from discovery to the first human trials, the P-Mapa course illustrates innovative ways to produce scientific knowledge. This approach can reduce the time and the money usually required to develop a new drug, as well as to conciliate interests from different groups and help to solve public health needs.

This strategy can be significant especially in developing countries. In Brazil, most drug candidates discovered in research institutes hardly go beyond the publication of papers, and Brazilian pharmaceutical companies only produce drugs derived from plants (used as analgesic or anti-aging agents), me-too compounds (e.g., to treat erectile dysfunction) or generic medicines, rarely addressing the public health needs [13,14].

As part of my doctoral research, I have followed 26 molecules presented over the past 15 years in international scientific journals and in Brazilian newspapers and general magazines as promising medicines. The molecules represented new hope against cancer, tuberculosis, pain, inflammation, arterial hypertension, Alzheimer’s disease, arthritis, epilepsy, mycosis, and ulcers, as well as typically tropical health problems such as Chagas disease and schistosomiasis. The scientists responsible for the research have stated, through the media, that these molecules would be evaluated in humans or be available as medicine in a few years. For various reasons, until 2010 none of the molecules has reached the promised goals.

Figure 2. P-Mapa purified: a medicine in the pipeline (Credit: Courtesy Farmabrasilis)

An unusual story

P-Mapa has had an unusual story. Initially, the physician Odilon da Silva Nunes worked for almost 40 years in a private laboratory, away from formal science research centers, to develop a molecule that could block tumors, according to his own hypothesis about the origin of cancer. The research advanced through collective work by other physicians and both non-academic and academic researchers who evaluated the compound’s properties according to drug development guidelines. In the 1990s, Farmabrasilis teams, led by Dr. Iseu Nunes as CEO and Prof. Nelson Duran as scientific director, scaled up the production and tested the compound on a group of HIV-positive people. Next, unable to forge alliances with pharmaceutical companies in Brazil, the research group reorganized, grew internationally and focused the research on infectious diseases, especially the most common in poor countries, such as AIDS and tuberculosis.

As a science writer and later as a PhD candidate, I have followed the P-Mapa story since 1991. I was privileged to visit the laboratories where P-Mapa was produced and talk to the scientists involved in this research. Their motivation to work voluntarily was “to satisfy idealism or curiosity, seek new challenges, hone skills, build a reputation or enhance careers”, as in other open source researches [15].

In 2007, as a Reuters Institute for the Study of Journalism Fellow at Oxford University, I examined how penicillin emerged in London and was later developed at Oxford. After comparing the course of the English and the Brazilian compounds, I concluded that their development is similar. Briefly, both started in the hands of physicians, moved ahead through a multidisciplinary task force and required overseas aid to be concluded [16]. However, the P-Mapa effect is broader, due to its ability to deter tumours, viruses and bacteria. Unlike penicillin, P-Mapa is a medicine in the pipeline.

References

1. Nunes I et al. United States Patent Application: US20060093628. “Protein aggregate magnesium-ammonium phospholinoleate-palmitoleate anhydride immunomodulator, its production process and formulation”.

2. Justo GZ, Durán N, Queiroz MLS. Myelopoietic response in tumor-bearing mice by an aggregated polymer isolated from Aspergillus orizae. Eur. J. Phamacol. 1999, 388: 219–226.

3. Farmabrasilis. P-MAPA toxicity and safety. Available from: www.farmabrasilis.org.br/todos conteudos interna.php?idioma=eng&id=217. [Accessed: 22th June 2010]

4. Farmabrasilis. P-MAPA clinical trial phase I. Available from: www.farmabrasilis.org.br/interna relatorios clinicos.php?idioma=eng&id=180 [Accessed: 22th June 2010]

5. Melo A, Justo GZ, Queiroz MLS. Stimulation of myelopoiesis in Listeria monocytogenes-infected mice by an aggregated polymer isolated from Aspergillus oryzae. Human Exp. Toxicol. 2001, 20: 38–45.

6. Justo GZ, Durán N, Queiroz MLS. Natural killer cell activity, lymphocyte proliferation and cytokines profile in tupour-bearing mice treated with MAPA, a magnesium aggregated polymer from Aspergillus orizae. Immunopharmacol. Immunotoxicol. 2003, 25: 305–319.

7. Farmabrasilis. P-Mapa Product Monograph. Available from: http://www.farmabrasilis.org.br/todos_conteudos_interna.php?idioma=eng&id=110 [Accessed: 22th June 2010]

8. Durán N, Gowene BB et al. A biotechnological product and its potential as a new immunomodulator for treatment of animal phlebovirus infection: Punta Toro virus. Antiviral Res. 2009, 83: 143–147.

9. Farmabrasilis. Assessment of the efficacy of the immunomodulator P-MAPA against M. tuberculosis in a standard mouse model. Available from: http://www.farmabrasilis.org.br/todos_conteudos_interna.php?idioma=eng&id=276 [Accessed: 22th June 2010]

10. Farmabrasilis. Infectious diseases proposal. Available from: http://www.farmabrasilis.org.br/pesquisa_desenvolvimento_interna.php?idioma=eng&id=255 [Accessed: 22th June 2010]

11 Rawlins MD. Cutting the cost of drug development? Nat. Rev. Drug Discov. 2004, 3: 360-364

12 Bhan A, Singh JA et al. Grand Challenges in Global Health: Engaging Civil Society Organizations in Biomedical Research in Developing Countries. PLoS Med. 2007, 4(9): e272.

13. Rezaie R, Frew S et al. Brazilian health biotech—fostering crosstalk between public and private sectors. Nat. Biotechnol. 2008, 26: 627-644.

14. Vidotti CC, de Castro LL, Calil SS. New drugs in Brazil: Do they meet Brazilian public health needs? Rev Panam Salud Publica. 2008, 24(1):36-45.

15. Munos B. Can open-source R&D reinvigorate drug research? Nat. Rev. Drug Discov. 2006, 5, 723-729.

16. Fioravanti C. New perspectives on drug development in developing countries: A case study of the Brazilian compound P-Mapa. Reuters Institute for the Study of Journalism 2007. Available from: http://reutersinstitute.politics.ox.ac.uk/fileadmin/documents/Publications/fellows__papers/2006-2007/NEW_PERSPECTIVES_ON_DRUG_DEVELOPMENT_IN_DEVELOPING_COUNTRIES.pdf [Accessed: 22th June 2010]

In this article, Sirina Keesara discusses the issue of misinformation as a barrier to use of family planning and slowing of population growth in Ghana.

From the invention of the birth control pill in 1960, and the subsequent proliferation of family planning programmes, access to contraception has expanded incredibly (1). Knowledge of at least one method of contraception is now nearly universal in almost all areas of the world, with pills, injectables, and male condoms as the most cited examples (2). Unfortunately, this improvement in knowledge has not been accompanied by an increase in contraceptive use. Use is especially low in Sub-Saharan Africa (2). The juxtaposition of these two findings seems to indicate that people who know about contraception don’t want to use it, probably because they want more children. However, this conclusion is inconsistent with the finding that more than 137 million women throughout the developing world do not want another child but are not using anything to prevent pregnancy (3). So why aren’t they using contraception if they know about contraception, but do not want to continue growing their families?

Researchers who have worked on this question for the past half century, have created a theory of fertility behaviour that attributes this gap in knowledge and practice to factors such as cultural traditions, low education rate, high mortality rate, and lack of women’s autonomy (4). The video at girleffect.org is one of the best popular culture products of this accepted theory. Using only animated words the video conveys a simple and powerful message: empower girls, change the world. At the start of the video, we see the word “girl” associated with the burdens of “child”, “husband,” “HIV”, and “hunger.” Then, with the introduction of “education”, all the burdens fall off, the music changes from gloomy to hopeful and the video rushes full force into the solution of education, micro-loans, and opportunity for girls to fix the world. The viewer is so elated by an elegant solution to complex problems, that many don’t notice one key omission: the family planning factor.

Rewind and click pause to the point when all the burdens fall off. How exactly are these burdens supposed to magically fall away? Giving a girl education prevents babies? No, not directly- only a condom or a set of pills (or any other form of contraception) can do that. Well, a girl will be able to obtain contraception if she has the opportunity for an education and a career… correct? Not necesarily!

The key, but faulty, assumption here is that women and couples will rationally weigh the costs (money or education lost, time that could be spent working, effort) and benefits of having a child and then will take necessary precautions to prevent any unwanted pregnancies (5). The first problem with this assumption is that, many times, children do not come as a product of rational decisions, but rather as a product of the passion of one moment. Therefore, because we have sex for reasons other than reproduction, we will produce babies without consistent contraceptive use. The second problem with the cost-benefit rationale is that it sets the cost of obtaining and using contraceptives very low. However, barriers to contraceptives are far greater than cost and distance to a family planning clinic. As revealed by interviews I conducted in Ghana, we have been successful in giving couples access to family planning, but we have failed to address other less tangible barriers.

Among the wide variety of barriers that exist in the field (6) many programmes have done little to explore or address issues such as misinformation surrounding contraceptives. Through interviews I conducted with women in Ghana, where the unmet need is s among the highest in the world at 34% (7), I found that the key element which holds women back from using contraception is misinformation; rumors, myths, and other pieces of faulty information prevent women, and especially young girls, from using contraception. If they believed that birth control will harm their body, health, or future fertility, they would not use it, even if a pack is placed directly into their hands. For example, the following woman working in a marketplace in the capital city, Accra said:

Sirina: you are afraid of the medicine. Okay, but what do you think will happen if you take it?
Woman: It will disturb you. Because if they say that if you use the medicine, it will destroy the womb. Because I am afraid of not having birth. If you don’t have birth, you won’t feel well in your self
Sirina: you don’t feel well as a woman.
Woman: yes! you are not feeling well. Some of them, they insult you if you don’t have births

Some even believed that abortion was safer than contraceptive pills because “it happened only once”, whereas contraception stifled fertility for an extended time. Abortions in Ghana, though legal, are highly restricted and largely unsafe.

Contrastingly, when the fear of infertility was taken away, many women jumped at the possibility to use family planning and limit their fertility. For example, one woman, who had thirteen children, was adamantly against the use of family planning because it went against God’s will. However, when she was asked, “would you use family planning if you were sure it was safe and it wouldn’t endanger your fertility?,” she answered: “oh of course.” This response was astounding because she seemed to have abandoned her religious reasons within a matter of seconds. When this question was included in all the subsequent interviews, the answer was almost always an emphatic “Yes!”

Furthermore, I found that women are badly in need of a method to control their fertility. One women was pregnant with her fifth child and had decided that she was going to take the “risk” of using family planning because she was so desparate to stop having children:

Interpreter: Well, she knew someone who had a problem with the family planning and they were trying to discourage her from it.
Sirina: But then why did she end up using it? I don’t understand why she would go for it.
I: That’s what I said that she wanted to give it a try and take the risk.
S: but if she took the risk she might not have been able to have babies again?
I: And she would have blamed herself for that. But she didn’t mind, she wanted to do it because she didn’t want any more [babies].

This widely found “intangible barrier” of misinformation meant that women had an ingrained belief that family planning was bad for fertility, and this belief played a large role in women’s reluctance to use it even when they wanted to control their fertility. Furthermore, it seems that when misinformation is removed women will act on their desire to have fewer children and will make a quick reversal of attitudes towards family planning. This can happen even without improvement in formal education or socioeconomic status. Other intangible barriers have a similar effect on women. For example, fear of maltreatment in clinics is potentially a huge hurdle. Despite Ghana’s Ministry of Health’s effort to train nurses and create youth-friendly clinics, these clinics are few and far between. For example, when I worked in a Family Planning Clinic, I witnessed the nurses “counselling” (scolding) a young client who wasn’t married before “getting into those things”. The girl was then forced to change her preferred method of contraception from the injection to the pill, because according to the nurse, that injection could make her sterile (it can’t), and she was sent away thoroughly embarrassed (8). Therefore, we can see that intangible barriers can be as significant or more than physicial availability of contraceptives.

Although intangible barriers are elusive to tackle, they are not insurmountable. For example, Iran, Bangladesh, and Thailand have all been able to ensure access to contraception for many women through community based distribution systems (10). In Iran, the increased governmental attention to family planning access and sexual education dropped the fertility levels (9) from 6.0 children/woman over her lifetime in the 1970s to 4.3 in the 1990s and then 2.1 in 2005 (10) – and inside a traditional culture. Case studies such as these raise questions about the validity of the accepted fertility behaviour theory; they show that fertility levels can drop and population growth can slow without improvement of other socio-economic variables. Therefore, it seems to imply that some factor, other than development, must influence fertility behaviours.

A newer theory of fertility decline, the opportunity model (11), says that women and couples will use contraception if they understand fertility regulation is an imaginable possibility. That is, if they believe they can use contraception without harmful side effects, they will want to use it and demand its availability! Think about it this way, before the internet we didn’t demand a connected web of information through which we could communicate almost instaneously. This demand was created by making such technology an imaginable possibility. Now that it is in our realm of possibility, almost nobody can live without it. In the early years of the internet, skeptics claimed that people would have to learn too many new skills to make use of it. However, Marc Andreesen, the creator of the first browser, replied “People will change their habits quickly when there is a strong reason to do so, and people have the innate urge to connect with other people- when you give them a new way to connect with other people, they will find it objectionable not to be able to”(12). Similarly, many academics have said that people would not adopt family planning because it would require too much behaviour change. However, I would argue that family planning opens doors to new options for women, and when they have access to contraceptive methods, along with correct information backed up with safe abortion, they will find it objectionable not be able to control their family size. In our work studying fertility preference and behaviours in Ghana, this pattern was clear; it seemed that women who learned that family planning was safe and easy to use, in other words who believed family planning was an imaginable possibility, would demand it and start to use it. Considering this theory we assume that the number quoted for unmet need is grossly underestimated because women with many intangible barriers may not realise that they have an option to control their fertility and thus may not express this desire.

This sheds new light on why family planning programmes in the past have not been as successful as expected. We need to redefine the way we think about barriers and tailor programmes to address these issues. If we are able to do this, we will be able to give women control over their own fertility, and by doing so slow rapid population growth. We cannot afford to ignore rapid population growth as this sole factor can ruin all our plans for the Millenium Development Goals and exhaust our world’s resources (13). If we ignore this issue, we are ignoring women’s rights and the rights of the future generations to come. We should encourage the international community to re-direct their attention towards family planning and understand its relevance in the underlying issues of health and development.

Sirina Keesara
Sirina.Keesara(a)ucsf.edu

References
1. Robinson WC; Ross JA. The global family planning revolution: three decades of population policies and programs. Washington, D.C., World Bank, 2007

2. Khan, Shane, Vinod Mishra, Fred Arnold, and Noureddine Abderrahim. Contraceptive Trends in Developing Countries. Calverton, Maryland, USA: Macro International Inc. 2007. DHS Comparative Reports No. 16.

3. Sedgh, Gilda et al. Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. New York: Alan Guttmacher Institute, 2007: Occasional Report No. 37. Accessible at http://www.guttmacher.org/pubs/2007/07/09/or37.pdf

4. Notestein F.W. Economic problems of population change. Proceedings of the Eighth International Conference of Agricultural Economists. London, Oxford University Press. 1953

5. In Gary Becker’s Nobel Prize winning book, Treatise on the Family, he uses economic principles to explain decisions and actions that pertain to the dynamics of the family. He includes on chapter about the Demand for Children in which he terms children as a high cost commodity and explains childbearing as a parent’s rational decisions about their “consumption” of children. ( cite his book)

6. Campbell, M.M. Sahin-Hodoglugil N. & Potts, M. Barriers to Fertility Regulation: A Review of the Literature. Studies in Family Planning, 2006: 37, 87-98

7. Gribble, Jay. Family Planning in Ghana, Burkina Faso, and Mali. Population Reference Bureau. April 2008. access on December 30th, 2009 at http://www.prb.org/Articles/2008/westafricafamilyplanning2.aspx

8. Keesara, Sirina. Barriers to Fertility Regulation for Ghanaian Women. Presentation at 137th annual APHA conference. Accessible at: http://apha.confex.com/apha/137am/webprogram/Session27587.html

9. Fertility levels are measured by Total Fertility Rate (TFR), the number of children that a woman (women, or a woman – hjave or has) would have in her /or their lifetime if fertility rates are constant. Replacement lvel fertility, in which each woman has the number children only replace the population is 2.1.

10. Gubaju, Bhakta, GUBAJU, BHAKTA. Fertility Decline in Asia: Opportunities and Challenges The Japanese Journal of Population. March 2007; 5:1

11. Campbell M, Bedford K.The theoretical and political framing of the population factor in development Phil. Trans. R. Soc. B 2009 364, 3101-3113.

12. Friedman, Thomas. Chapter 2. The World is Flat: A Brief History of the Twenty-First Century.

13. All Parliamentary Group on Population Development and Reproductive Health, “Return of the population Growth Factor: Its Impact on the Millenium Development Goals” (HMSO, London, 2007). www.appg.popdevrh.org.uk Accessed on December 27th 2009

In today’s article, Rohan Mongru, fourth year medical student from Barts and The London School of Medicine and Dentistry duiscusses the implementation of the Cuban healthcare model into Niterói, Rio de Janeiro.

Fig 1. The favela of Morro do Palácio

Niterói and her favelas
Approximately 30 years ago, the city of Niterói in Rio de Janeiro, Brazil, restructured its healthcare system. Epidemics of dengue fever and meningitis served as a catalyst for Niterói to take advantage of Cuba’s global offer of assistance. Niterói and Cuba opened negotiations in 1989 and officially formed a partnership in 1991: the “Family Medical Programme” (Projeto/programa médico de família, PMF) . During this time, the number of reported dengue cases in Brazil rose from 1570 in 1989 to 104 338 in 1991. [1] Similarly, there was a rise in the number of Neisseria meningitidis infections reaching a peak in 1991 of approximately 350 cases/100,000 people. [2]

Niterói contains 40 of Rio’s 600 favelas or “shanty towns”. Today, almost a fifth of Rio’s population live in favelas – around 1.5 million people, and this number is growing. Recently, favelas have become synonymous with violence and drug-related crime. These ubiquitous towns are usually made up of self-constructed clay-tiled domiciles on peripheral third-party or unused areas such as the picturesque Rio favelas overlooking the city. (fig 1)

A community centre, shops and tradehouses are all contained within. Schools do exist but most residents do not finish basic schooling and very rarely become educated enough to make use of the free but prohibitively competitive higher college education. Healthcare was almost non-existent until the PMF assistance; those needing healthcare simply left a message with the local hospital and relied on the goodwill of a doctor to see the patient in their own time. This indicates that the inhabitants thought of healthcare as emanating from doctors and nurses within hospitals.

The Cuban Healthcare Model
Even before Castro’s social revolution, Cuba enjoyed a reputation for excellent healthcare. Like a number of other countries her methods of education and practice were based on a number of ground-breaking theories. One of these, The Flexner Report, of 1910 [3], led to an integration of laboratory-based science into the preclinical years, with the clinical component taught within teaching hospitals. Another, the Dawson Report [4], was published in 1920 by Lord Dawson of Penn, a Royal Physician. His visionary report laid out the concepts of districts and regional services, proposing a hierarchical system with community based Primary Health Care centres staffed by General Practitioners (GPs) and support staff.

Nearby, secondary health centres would provide extra medical services. These were associated with tertiary care university hospitals where complicated cases could be managed. The role of preventative as well as curative medicine was especially stressed. Further; Lord Dawson stated that a doctor need not train wholly within a hospital and the GP forerunner should work within the community among their patients.

Fig 2. The Module in Palácio favela

Fidel Castro famously made free healthcare for everyone a major part of his revolutionary ideals. He has shared his knowledge and resources with many countries around the world, especially within Africa and Latin America. Castro viewed four cornerstones as the foundation of a successful country: medicine, military, education, and agriculture, offering assistance in each area. [5] In 2006, according to the World Health Organization, Cuba’s under-5 mortality was 7 per 1000 births and the average life expectancy was 78 years. [6]

The UK, by comparison, listed under-5 mortality figures at 6 per 1000 births but Cuba was superior to the US with its 8 deaths per 1000 births. It should be noted, however, that Cuba still has a very high abortion rate since its legalisation almost 40 years ago. [7] Gapminder [8] lists the inflation-adjusted income per person in Cuba at $8948 in 2007, as compared to $33 203 in the UK with a similar life expectancy of 79 years; and $42 952 in the US with the same life-expectancy! Brazil’s mean income per person in 2007 was $9066. This was comparable to Cuba, but their life-expectancy, at 72 years, was much lower.

Structure of the Model
PMF criteria [9] defined the territories to be helped as those containing inhabitants with low incomes; unassisted by local authorities but containing existing “Resident Associations” (usually consisting of community elders) able to coordinate with the PMF. These groups are essential in facilitating the work of the healthcare team by aiding their integration into the communities as well as identifying health problems and assisting in their solutions.

Each “micro-area” is divided into sectors enclosing an average of 1200 people. Each sector is covered by a Basic Team (doctor and auxiliary) and a few sectors make up a Module (fig 2): GP surgery equivalents and entry point to the healthcare system. Each Cuban medical graduate completes three years in General Practice, illustrating a more generalist approach. [10] Cuban staff are required to live within the immediate vicinity of the Module in provided housing. However, in Brazil these areas are not considered safe enough to make this a viable requirement.

Each Basic Team’s day is divided into halves: either in clinic (consultario) or out in the field (campo) making house calls or registering people in the area (cadastre). Everyone is offered an initial appointment where one is introduced to the clinic and an introduction is established. This check-up is part of the team’s preventative and educational role, theoretically allowing the doctor to plan for possible future diseases.

Extra care of high-risk patients is a focal point of this model. Lifestyle advice and medication may then be recommended to the patient, or further tests requested in the polyclinics. (fig 3) Patient data from all the favelas in Niterói is collated centrally, where global trends are monitored. The teams are required to identify and tackle modifiable health behaviours in the community including smoking, breast-feeding, diabetes, contraception, and the importance of drugs adherence in HIV and tuberculosis. The government contributes financially towards food for people diagnosed with HIV, and for school-aged children’s clinic visits and vaccinations.

Fig 3. A Polyclinic in downtown Niterói

Basic Working Groups (Grupo Basico de Trabalho, (GBT)) each offer support to up to 20 Basic Teams. Each GBT consists of a coordinator and a multidisciplinary team of “supervisors”: a general physician, paediatrician, obstetrician/gynaecologist, health worker, social worker, nursing specialist and psychiatrist/psychologist. Coordinators liaise between the group and the Basic Teams, Residents Associations, government health departments and other external staff. Each supervisor visits each of the Modules weekly, and then problems can be addressed – for example, complicated cases are reviewed, medical services evaluated and areas for training identified. These issues are then shared with all the Family Doctors during weekly group meetings where pertinent problems may be discussed; for example, the increased prevalence of tuberculosis cases.

Concurrently, Niterói’s Municipal Foundation of Health created a 5-tier hierarchical healthcare structure that would cover the entire half a million Niterói inhabitants. Modules are the first level, with community clinics placed above them in the hierarchical system and which serve as gatekeepers for specialized polyclinics. Central offices navigate the patients through the system. Hospitals sit at the top of the hierarchy with university hospitals providing care in all specialities.

Conclusion
The Cuban emphasis on a Primary Health Care-based model addresses the accessibilty and focused care needs of the inhabitants of the favelas. Medical staff have roles in the community and in active disease prevention. They walk the alleyways, learning about their patients (many of whom cannot read and do not own computers or phones) and their homes, noting healthcare issues affecting the community and promoting health in an individualistic as well as a communal manner.

The work of the PMF is ongoing and more coverage is needed: 75 more Basic Teams (for a total of 135) and at least four more GBTs are required in Niterói. Assessing the new system is difficult, as little information exists about the inhabitants from a time when there was no healthcare present.

But simply providing healthcare to those who have had none is an achievement. Data provided by Dr. Suely, a senior coordinator, shows that the under-5 mortality rate is 14.7 per 1000 babies in Niterói compared with 22.4 in the rest of Brazil [6]; however, this is attributable to many factors. For example, breast-feeding has increased in the past 20 years, a national strategy promoted within the communities by the PMF; immunization schedules have been formalised; care and nutrition of children with diarrhoea caused by rotavirus have improved, resulting in the decline of reported cases.

Nationally, the situation is less rosy. [11] The government provides healthcare for 75% of Brazil’s population whilst the remaining quarter uses private health care. The national PMF equivalent – the Family Health Programme (Programa de Saúde da Família, (PSF)) – employs 28 300 teams of doctors, nurses, and dentists to treat over 90 million people from their health clinics. Free vaccinations and targeted care has seen the infant mortality decrease by 60.5% since 1990 and the life expectancy steadily rise from 67 years in 1991. However, concentrating on Primary Health Care and generalist family doctors meant that specialised care suffered through insufficient funding. There is a lack of specialist clinics and trained staff, emergency clinics and public hospitals, resulting in overcrowding and inadequate care for the 15% who require specialist care.

Dengue and dengue haemorrhagic fever has not been eradicated and is still present in large numbers. In 2008, there were 32 615 recorded cases of dengue fever in Rio de Janeiro from January to March. [12] The Ministry of Health worked with relevant local institutions, including the PMF in Niterói, to identify and implement appropriate interventions to identify sufferers and eradicate the mosquito vector.

Cuba (and now Niterói’s favelas) certainly benefits greatly from a high healthcare worker: patient ratio – 1 doctor per 175 people and 1 GP per 600 people and almost 27 000 more nurses than the UK for a fifth of the UK’s population. [10] Ironically, some of Cuban good health is due to the adverse conditions in that country.

The rationing of food and scant supplies of meat mean that there is a higher proportion of fruit and vegetables in the Cuban diet. Many people walk or cycle, due to a scarcity of transport. [10] However, junk food and low activity are prevalent in the favelas despite the relatively lower cost of greens. Regardless, it is the relationship between the GP and the patient that seems to be at the heart of Cuba’s success; something that should not be lost both in Brazil and in the UK.

Rohan Mongru
ha06765@qmul.ac.uk

Acknowledgements
I am indebted to Dr. Jeanette Naish for tutoring me on the project. This article is dedicated to Ilana Marques who arranged the project from Rio de Janeiro, and who provided the photos. Drs. Hübner, Suely, Veronica and Augusto together with Leandro Nogueira looked after me in Brazil.

1. Figueiredo, L.T.M. 2003. Dengue in Brazil: Past, Present and Future Perspective. Dengue Bulletin 27:25-33

2. Barroso, D.E. and Rebelo, M.C. 2007. Recognition of the epidemiological significance of Neisseria meningitidis capsular serogroup W135 in the Rio de Janeiro region, Brazil. Memórias do Instituto Oswaldo Cruz. 102(6): 773-775

3. Flexner, A. 1910. Medical Education in the United States and Canada Bulletin Number Four (The Flexner Report). New York: The Carnegie Foundation for the Advancement of Teaching, New York: The Carnegie Foundation for the Advancement of Teaching.

4. Great Britain, Ministry of Health, Consultative Council on Medical and Allied Services. 1920. Interim report on the future provision of medical and allied services. (Chairman: Lord Dawson). London, HMSO, 1920. Cmd 693; Dawson Lord. Medicine and the State. The Medical Officer, PRO/MH/73/49.

5. Bourne, P.G. 1987. Castro: A Biography of Fidel Castro. MacMillan

6. World Health Organization Mortality Country Fact Sheet 2006. http://www.who.int/whosis/mort/profiles/mort_amro_cub_cuba.pdf

7. United Nations Statistical Division. 2008. Legally induced abortions by urban/rural residence of woman. http://data.un.org/Data.aspx?d=POP&f=tableCode%3a17

8. Gapminder. http://www.gapminder.org

9. Hübner, L.C.M. and Franco, T.B. 2007. O programa médico de família de Niterói como estratégia de implementação de um modelo de atenção que contemple os princípios e diretrizes do SUS. Physis. 17(1)

10. Pietroni, P. 2001. Cuban Health Care Systems and its Implications for the NHS Plan; a Memorandum (PH 97).

11. Kepp, M. 2008. Cracks appear in Brazil’s primary health-care programme. The Lancet 372(9642):877

12. Pan American Health Organization (PAHO). 2008. Dengue in Rio de Janeiro, Brazil. EID Updates: Emerging and Re-emerging Infectious Diseases, Region of the Americas. 5(9). http://www.paho.org/English/AD/DPC/CD/eid-eer-2008-03-26.htm

In today’s article, Shirin Mirza, MSc student of Epidemiology & Biostatistics from the Aga Khan University, Karachi, Pakistan, discusses Canada’s healthcare system.

Abstract
Canada has made remarkable progress in promoting health of its citizens in the last 35 years. This has been possible by emphasizing on health promotion in the Lalonde report in 1974, the Ebb report in 1986 and in the Ottawa charter in 1986. Still the health outcomes depict a diverse social & regional picture. Inequity in health in Canada is due to unaddressed social determinants of health, poverty being the most significant

Introduction
Canada, a nation of 33.1 million people [1], functions as an egalitarian society. [2] It provides comprehensive healthcare to all its citizens through publicly funded healthcare system. [3] Despite the universal access to healthcare, health status of Canadians is ranked 10th among the 16 peer countries. [4] This situation can be attributed to the unaddressed social determinants of health.

This report looks into the health promotion and healthcare services in Canada and its impact on the health outcomes. It will look into the challenges faced by policies for health and healthcare systems that will give an insight into the potential solutions.

Health promotion, policy for health & health service delivery
A model of health promotion in Canada was first proposed in the benchmark report of Marc Lalonde in 1974. [5] This report argued that illness, disease and disability are national problems which can be solved by addressing the issues pertaining to lifestyle, environment, organization of healthcare services and human biology. [5] This was followed by Ebb report in 1986, which in addition to self-care for health, addressed in previous report, emphasized on greater role of community healthcare. [6] It highlighted that reducing inequity is fundamental to health promotion. [6] Sociopolitical factors as well as social justice and equity were stressed upon as ‘pre-requisites for health’ in the Ottawa Charter in 1986. [7] It also recognized the importance of inter-sectoral approach and community participation for better health of the individuals. Concept of ‘social, environmental and cultural determinants of health’ was reinforced in the report by Health Canada and Canadian institute of health information in their individual reports in 2004. [8, 9]

Despite all these efforts for a healthy public policy, healthcare delivery is largely hospital-centered and focuses on acute healthcare. [10] Under the Constitution Act 1867, provincial government is responsible for establishment, maintenance and management of hospitals, asylums, charities and charitable institutions. [11] The Federal Government is responsible to investigate into public health, regulate food and drugs and administer healthcare insurance. [11] It has ‘Spending power’ and committed to one-half of whatever the provinces spend on healthcare coverage under the Medical Care Act 1966. [12] Federal healthcare funds are now allocated to the provinces under Canada Health Act of 1984. [12] The government pays about 70% of healthcare costs and 30% is paid by the private sector. [3] Under this form of health policy, all Canadians enjoy publicly funded healthcare which is mostly free at point of use, with services provided by private entities. [3] Medication cost is paid by public funds for elderly and indigenous or by employment based private insurance. [3]

Health outcomes
Health outcomes depict a diverse regional and social picture.

Table showing life expectany at birth in Canada (in yrs) [13]

Life expectancy at birth ranged from 76.3 yrs in Northern territories to 81.2 yrs in British Columbia. [13] Cancer is the leading cause of death followed by heart disease and cerebrovascular diseases [14]; the poor are more likely to suffer from heart attack. [15] In Ontario, the premature mortality rate (death before 75 yrs) is 310/100,000 for males and 190/100,000 for females; the difference in premature mortality between poor and rich being 203/100,000 & 73/100,000 for males and females respectively. [16] Infant mortality varies from 0/1000 live births in Yukon to 10/1000 in Nunavut [17]; it is 60% higher in poor Ontario neighborhoods than national average. [15]

Prevalence of diabetes has increased by 21% between 2002 and 2007 [18]; poor women in Ontario were four times more likely to suffer from diabetes than high-income women. [15] One in 16 people suffer from diabetes and mortality rates for diabetics 20 years or older is twice that of non-diabetics. [18]

Situation analysis: inequity in health & challenges for health policies
Though Canada is a reasonably healthy country, unequal health in the rich and poor strata of Canadian society as well as regional diversity depicts a gloomy picture. Why is there this disparity despite a good healthcare insurance system?

As recognised in the reports for health promotion from 1974 to 2004, health and well-being requires not only good healthcare systems, but also a conductive sociopolitical environment which can be achieved by addressing the social determinants. [8] Poverty is one such social factor that needs to be addressed; others being racialisation, immigration and settlement status, and education. [16] These latter determinants interact with income to have an impact on health and well being of the Canadians. [16] It is noteworthy that association of poor health and poverty is not only comparing the poorest to the richest, but it means that those living in high income areas are healthier than those living in middle income areas and these in turn are healthier than those living in low income areas. [16]

Provincial governments have set their health goals that take into account various determinants of health [19] and many provinces have started working on it, but are not at an equal pace. [20] It must be realized that main implication of the ‘nonmedical determinants’ lie outside the health sector. [21] Policies relating to finance, education and social services can impact these determinants and thus can influence health. For example the problem of childhood obesity (34% in boys and 23% in girls 12-17 yrs old [22]) can be solved not only be physical education at school but also by healthy diet and public transport which can make children walk regularly. This in turn will decrease the use of private transport thus address the problem of pollution which will decrease the rate of respiratory diseases. This scenario shows that this health problem can only be dealt with by combined efforts of education, food and transportation sector which are governed by public policies. Moreover these policies should target ‘collectivist rather than individualistic ethos’. [10]

Other lifestyle factors like smoking, alcoholism and eating habits can be addressed likewise.

Conclusion
Social groups have to be identified to address the inequities in health in Canada. Moreover inter-sectoral approach is required to attain health for all in Canada.

Shirin Mirza
shirinmirza83@hotmail.com

1. Bureau of Western hemisphere affairs. Background note: Canada. (accessed February 15, 2010) Available from: http://www.state.gov/r/pa/ei/bgn/2089.htm

2. Islam MK, Merlo J, Kawachi I, et al. Social capital and health: Does egalitarianism matter? A literature review. Intern J for Equity in Health 2006; 5.

3. Healthcare in Canada. (accessed February 15, 2010); Available from: http://en.wikipedia.org/wiki/Health_care_in_Canada

4. The Conference Board of Canada. Health. September 2009 (accessed February 6, 2010); Available from: http://www.conferenceboard.ca/hcp/details/health.aspx#Indicators

5. Lalonde M. A new perspective on the health of Canadians. 1974. (accessed February 6, 2010) Available from: http://www. hc-sc. gc. ca/hppb/phdd/pdf/perspective. pdf.

6. Epp J. Achieving health for all: A framework for health promotion. Health Promotion International 1987;1.

7. World Health Organization. Ottawa Charter for health promotion. 1986 (accessed February 7, 2010); Available from: https://www.who.int/healthpromotion/conferences/previous/ottawa/en/

8. Approach O, Renaud M, Good D, et al. Canada Health Action: Building on the Legacy-Volume II-Synthesis Reports and Issues Papers. 2004 (accessed February 15, 2010); Available from: http://www.hc-sc.gc.ca/hcs-sss/pubs/renewal-renouv/1997-nfoh-fnss-v2/legacy_heritage4-eng.php

9. Beauchamp J, Blaauwbroek M, Brulé C, et al. Improving the health of Canadians. In: Ottawa: Canadian Institute of Health Information; 2004.

10. Low J, Riault. LT. Health promotion policy in Canada: lessons forgotten, lessons still to learn. Health Promotion International, 2008; 23:200-206.

11. Chenier NM. Health policy in Canada. 2002 (accessed February 5, 2010); Available from: http://dsp-psd.communication.gc.ca/Pilot/LoPBdP/CIR/934-e.htm

12. Makrenko J. Canadian Federalism and Public Health Care: The Evolution of Federal-Provincial Relations. Health, Education & Social Welfare 2008 (accessed February 10, 2010); Available from: http://www.mapleleafweb.com/features/canadian-federalism-and-public-health-care-evolution-federal-provincial-relations#1970

13. Canada Human resource and skills development. Health-life expectancy at birth. Indicators of well being in Canada (accessed February 5, 2010); Available from: www.hrsdc.gc.ca

14. Statistics Canada. Leading causes of death. (accessed February 10, 2010); Available from: www.statcan.gc.ca

15. Rachlis M, Bloch G, Tamari I. Poverty makes Ontario sick: Economic inequality translates into limited access to health-care for province’s poor. The Star August 5, 2008.

16. McKeown D, MacCon K, Day N, et al. The unequal city: Income and health inequalities in Toronto; October 2008.

17. Canada Human resource and skills development. Health-Infant mortality. Indicators of well being in Canada (accessed February 5, 2010); Available from: www.hrsdc.gc.ca

18. Public health agency of Canada. Report from the National Diabetes Surveillance System: Diabetes in Canada, 2009. (accessed February 8, 2010); Available from: http://www.phac-aspc.gc.ca/

19. Toward a Healthy Future: Second Report on the Health of Canadians. Ottawa, Ontario, Canada: Federal, Provincial and Territorial Advisory Committee on Population Health; 1999

20. Romanow R. Fight poverty to improve economic and social health. The Star December 2, 2008.

21. Lavis JN. Ideas at the margin or marginalized ideas? Nonmedical determinants of health in Canada. Health Aff (Millwood) 2002;21:107-12.

22. Canada Human resource and skills development. Health-obesity. Indicators of well being in Canada [cited 2010 February 5]; Available from: www.hrsdc.gc.ca

In today’s article, Joseph Fitchett from the London School of Hygiene & Tropical Medicine writes about Medicine during the Second World War.

“For ever let this place be a cry of despair and a warning to humanity where the Nazis murdered about one and a half million men, women and children, mainly Jews from various countries of Europe.”
Memorial Tablet at Birkenau Concentration Camp

Historical Background
Following defeat of the First World War in 1918, the recently united Germany was left isolated and facing severe sanctions. Germany signed the Treaty of Versailles and, as a consequence, lost over 10 percent of its territory and all its overseas colonies, in addition to which it was set to pay crippling sanctions, prohibited to annex neighbouring states and it had the size of its army greatly capped.

The Weimar Republic, a liberal democracy, was instilled in 1919 to govern Germany. It was difficult, however, to reach a single party majority with its system of proportional representation, resulting in coalition governments that found it near impossible in its early years to control left and right wing extremism, attempted coup d’états, rampant inflation and economic meltdown.

Despite the “Golden Era” from the mid-1920s, political instability within Germany and the crisis of the Great Depression worldwide contributed to the strengthening of popularity of the National Socialist German Worker’s Party (the Nazi Party) with many Germans still humiliated by the terms of the Treaty of Versailles.

The Nazi Party, promoting German nationalism, was racist, anti-communist and anti-capitalist, with its leader Adolf Hitler aspiring to establish a “New Order” of Aryan supremacy in Europe. In 1933, president Paul von Hindenburg appointed the increasingly popular Adolf Hitler as Chancellor for another coalition government in an attempt to keep him under close control.

Ultimately, following more turmoil including a devastating fire at the Reichstag (German Parliament building) blamed as a communist plot, Hitler swiftly began dismantling restrictions of power and expanding his command and German territory, eventually leading to the Second World War.

The Eugenics Movement
The eugenics movement of the early 20th Century was not a phenomenon exclusive to Nazi Germany. The aim was to improve the human species by controlling birth and offspring. Compulsory sterilization was a key mechanism to reach this end.
Eugenics inevitably raises concerns violating human rights, namely the right to life, privacy and freedom from discrimination. However, it was at the time justified in both utilitarian and Darwinian terms.

Controversy over eugenics and the Nazi desire for “racial hygiene” and extermination of certain distinct population groups is highlighted by the fact that other countries applied eugenic policies to differing degrees. The United States of America, Britain, Sweden, Belgium, Canada, Australia and others enforced, in different degrees, compulsory sterilization based on criteria such as mental health, social class, sexuality, and crime.

It was in this controversial climate that the Nazi Party began outlining its increasingly severe interpretations of the eugenic movement of the 1930s and applying it to an unparalleled scale for “Volkwerdung”, or becoming a master race. Hitler increasingly began to see society as a “biological organism” and became fixated on promoting what he believed to be healthier elements. [1]

The “common good” began to carry more importance than the “individual benefit” and economic justification was increasingly used. A slippery slope towards fulfilment of “Volkwerdung” led to an expansion in involuntary euthanasia. Inspired by a 1920s treatise entitled “Release through the Annihilation of Life Unworthy of Living”, involuntary euthanasia was initially confined to the asylums but soon expanded into hospital practice.

The next step, genocide, is extreme but was central to the “racial hygiene” sought by the Nazi Party. [2] The spectrum from compulsory sterilization to involuntary euthanasia and to genocide is broad and chronologically apparent in the Third Reich. Supervised by doctors, they are a chilling reminder to those in the healthcare profession of the importance of a patient-centred relationship for the protection of those most vulnerable.

Nazi Human Experimentation
Enforced scientific experimentation by the Nazis is shocking simply in its nature and compounded by the fact that doctors, respected as protectors of life, carried out the research in labour and concentration camps. Experiments included genetics, experiments on twins, exposure to extreme conditions (including freezing temperatures and high altitudes), infectious diseases and pharmacology.

Many experiments were done in the aim of understanding the conditions a soldier might encounter during the Second World War. Freezing experiments for the Luftwaffe (Nazi air force) would therefore involve a simulation of harsh conditions followed by an attempt at resuscitation. The experimental subjects would then be subjected to very hot temperatures, such as in a bath, which they could succumb to.

Further experiments for pilot survival included analysing the effects of drinking seawater. Some prisoners were subjected to mustard gas in an effort to investigate treatment of their wounds. Other prisoners were deliberately infected with malaria.

Dr Josef Mengele, a physician and Schutzstaffel (SS) officer, was the notorious medical officer at Auschwitz and chief medical officer at Birkenau. Particularly interested in experimentation on identical twins, Mengele initially treated his subjects well. However, from around 3,000 twins only 52 are known to have survived Auschwitz. [3]

Mengele was even referred to as the “White Angel” as he inspected the new arrivals to Auschwitz and Birkenau concentration camps, directing them either to the right or to the left, indicating their immediate fate: hard labour or the gas chambers.

Nuremberg Trials and the Nuremberg Code
Following the end of the war, the Allied Forces (France, the United States of America, the Soviet Union and the United Kingdom) put on trials for suspected war criminals. Political differences between the Allies at the end of the Second World War resulted in diplomatic difficulties over continuing to use the International Military Tribunal that had operated in 1945-46.

Instead, 12 trials were held before United States military courts in the city of Nuremberg in the American-occupied zone. The Doctors’ Trial, December 1946 to August 1947, brought 23 defendants to trial facing accusations on four charges, namely: conspiracy to commit war crimes and crimes against humanity, war crimes, such as performing medical experiments without the subject’s consent, crimes against humanity, and membership of a criminal organisation, such as the Schutzstaffel.

Prosecutors concentrated on the experimentation within the camps. Seven war criminals were acquitted, seven sentenced to death (including Karl Brandt, Hitler’s personal physician), and the remaining nine received sentences of imprisonment.

The trial led to the Nuremberg Code – a set of biomedical research ethics principles addressing non-therapeutic experimentation on human subjects, with the first principles emphasising that the “voluntary consent of the human subject is absolutely essential”. [4]

The impact of the Nuremberg Code on medical ethics can be felt to this day with subsequent statements such as the 1964 Declaration of Helsinki [5] and 1978 Declaration of Alma Ata [6] emphasising ethical principles for human experimentation and promoting health as a human right, respectively.

Reflections
The Auschwitz camp complex, including the Birkenau extermination centre, stands today as a poignant reminder to prevent exploitation of those most vulnerable. It feels almost impossible to comprehend how such atrocities could have taken place.

The fact that human beings are capable of the most inhumane of thoughts and actions is unsettling. Patients trust their doctors and healthcare professionals often at times of great despair. Accordingly, doctors have an unparalleled responsibility to protect the individuals they treat and care for, and must respect their patients’ autonomy, always seek their consent and do them no harm.

Through experimentation, hard labour and murder, the prisoners in the Nazi concentration camps were dehumanised and subjected to the gravest violations of their human rights. The presence of a medical professional can often be seen to justify a procedure, particularly relevant to this day with accusations of supervised torture.

Acknowledging and protecting an individual’s fundamental rights and never treating them merely as a means to an end are two of the most important principles we must all actively promote throughout our lives to safeguard humanity.

“A destruction, an annihilation that only man can provoke, only man can prevent”
Elie Wiesel, Holocaust survivor and Nobel Laureate

Poem extract from Primo Levi’s If This Is a Man [7]

Consider if this is a man
Who works in mud,
Who knows no peace,
Who fights for a crust of bread,
Who dies by a yes or a no.
Consider if this is a woman
Without hair, without name,
Without the strength to remember,
Empty are her eyes, cold her womb,
Like a frog in winter.

Joseph Fitchett
Joseph.fitchett@doctors.org.uk

Acknowledgments: The author would like to thank Professor Michael Biddiss, FRHistS, for his comments.
For further reading, see references 8, 9, 10 & 11.

1 Biddiss M. Disease and dictatorship: the case of Hitler’s Third Reich. J Royal Soc Med 1997;90:342-6

2 Annas G, Grodin MA. The Nazi Doctors and the Nuremberg Code. Oxford University Press, 1995

3 Lagnado LM, Dekel SC. Children of the Flames. Penguin, 1991

4 The Nuremberg Code. Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No.10, Vol.2, pp 181-2. US Government Printing Office. Washington DC, 1949

5 World Medical Association. Declaration of Helsinki – Ethical principles for medical research involving human subjects. Helsinki, 1964

6 World Health Organisation. Declaration of Alma Ata. International Conference on Primary Health Care. Alma Ata, 1978

7 Levi P. If This Is a Man. Abacus (English translation 1958), 1947

8 Caplan A (ed) When Medicine Went Mad. Bioethics and the Holocaust. Totowa, Humana Press, 1992

9 Special Issue on the Nuremberg Doctors’ Trial. BMJ 7 December 1996

10 Proctor RN. Racial Hygiene. Harvard University Press, 1988

11 Weindling P. Health, Race, and German Politics, 1870-1945. Cambridge University Press, 1989

In today’s article, Samrah Zaigham discusses end of life care and patient-physician communication. Read it here

In today’s article, Matt Quinn discusses the relation between folic acid supplementation and neural tube defects.

Each year approximately 220,000 babies are born worldwide with spina bifida or anencephaly due to maternal folic acid deficiency during the periconceptual period. [1] These cases account for roughly 70% of the global incidence of spina bifida and anencephaly and have been termed folic acid-preventable spina bifida and anencephaly, respectively. Fortifying food with folic acid could prevent these debilitating illnesses. The current RDA of 400 mg can be found in most over-the-counter multivitamins. This paper will provide a brief overview of the pathogenesis of spina bifida and anencephaly, the evidence supporting the use of folic acid supplementation during the periconceptual period, the disparities between different countries use of folic acid fortified food, and the ethical and safety concerns for why some countries have chosen not to implement mandatory folic acid fortified food programmes.

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Poverty leads to conflict and conflict leads to greater poverty and an inability to effectively respond to health disasters

The world is currently trapped in a humanitarian crisis of epic proportions. This crisis is poverty. Article 25 of the Declaration of Human Rights states, ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family.’ [1] Despite this 3.2-3.8 billion people (51-60% of the world’s population) live below the ‘Ethical Poverty Line’, defined as the income level below which further income losses materially shorten life expectancy [2]. Every year 10 million children in the developing world die from preventable causes including diarrhea, pneumonia, measles, malaria and HIV/AIDS: in over half of these deaths malnutrition is an underlying cause [3].

These deaths can be directly linked to poverty because with the appropriate resources they are preventable. As illustrated on the graph below [4], poverty is a humanitarian crisis of epic proportions. The poverty related child deaths in just one year reach a death toll exceeding that of World War II.

Figure 1: Graph illustrating the death toll of 20th century atrocities and the deaths of young children from poverty in one year

Many of the world’s current humanitarian crises are a result of underlying global poverty. Collier’s studies show that low income and slow growth make a country prone to civil war [5]. A country with a gross domestic product (GDP) of US$250 per capita has a 15% probability of a war in the next five years. A country with a GDP of $600 per capita has approximately half of this probability [6]. Natural disasters are likely to impact poor countries more severely because poorly developed infrastructures and lack of resources make preparation and appropriate response difficult. If Haiti were not so poverty-stricken, the country may have been able to improve its physical infrastructure to prevent the terrible devastation caused by the recent earthquake. Poverty produces poor health and makes communities more susceptible to disease but contrarily also means effective treatment is unaffordable [7]. Conflicts, which are more likely to occur in poverty-stricken countries, both cause and exacerbate disease epidemics A vicious cycle is then created: poverty leads to conflict and conflict leads to greater poverty and an inability to effectively respond to health disasters.

Poverty has many causes but there is increasing recognition that international policy can have a negative or positive impact depending on its nature [8]. The World Bank has promoted a predominantly neo-liberal approach to poverty reduction. This approach relies on the trickle down of wealth through society to alleviate poverty [9] with social safety nets to protect the poorest [8]. According to the Bank’s definition of poverty the number of people living in extreme poverty has decreased. [10] The Bank’s criteria have been criticized however, since when the ethical poverty line is used the numbers have increased by 22-30% in the last thirty years [2]. The reality of this trickle down effect is challenged by the fact that in America, one of the richest countries in the world, with a predominantly neo-liberal approach to policy, one quarter of children lived in officially defined poverty in the year 2000 [11].

In the 1980s neo-liberal policy was introduced in many developing countries in the form of Structural Adjustment Programs. These policy packages developed by the World Bank and IMF reduced the role of the state and encouraged privatization. User fees were introduced in these countries health systems resulting in less people accessing healthcare [9]. Market liberalization was encouraged but a study published by the World Bank later found that it correlated with a decrease in income growth in the poorest 40% of the population [12]. A neo-liberal market approach is efficient at making the rich richer but not so efficient at making the poor richer. In 2000 the US’s top four hundred tax payers had a combined income that exceeded the combined income of Botswana, Nigeria, Senegal and Uganda [13].

It is important to note that the recommended neo-liberal policies have not been uniformly implemented. Some international policy disregards neo-liberal recommendations in order to favor the interests of the rich. The Trade Related-aspects of Intellectual Property Rights (TRIPS) agreement jeopardizes the generic drug industry in developing countries in order to protect the profits of the pharmaceutical industry [14]. It extends patents in spite of the fact that the current patent system is economically inefficient and causes losses of a much larger scale than those caused by tariffs and trade barriers [16]. Another example of the hypocrisy in international trade related policy is subsidies. Although the World Trade Organization has encouraged poor countries to stop subsidizing their farmers the rich countries continue this practice. European citizens are currently paying $2 per cow in subsidies when half the world’s population lives off less. It is impossible for poor farmers to compete with farmers in European countries who enjoy an average of $14,000 a year in subsidies [15]. Many countries are also paying more in debt than they receive in aid. These debts became un-payable partly because of the subsidies introduced by rich countries in the 1980s [9]. Protectionism and tariffs persist and it may be that fairer trade liberalization would have more benefits for the poor [17].

However even if proven to be effective, a pure neo-liberal approach is arguably not the most efficient poverty reduction strategy. Currently each $1 of poverty reduction acquired in this way requires $166 of additional global production and consumption with the associated environmental consequences having the biggest impact on the poor [7]. There is also evidence to suggest that the wealth inequality inherent in neo-liberalism is itself health damaging. Wilkinson’s research indicated that societies with more unequal distributions of wealth generally have poorer outcomes across a range of indicators [18].

It is irresponsible to place the lives of millions in the invisible hands of the market rather than in the hands of governments who can act to solve the problem. The resources already exist to alleviate extreme poverty. The United Nations Development Program estimated the additional cost of achieving basic social services for all in developing countries at about $40 billion a year between 1995 and 2005. This is less than 0.2% of world income [2]. Ending poverty needs to be prioritized and economic growth needs to be viewed as the means rather than the end of development and as one of many tools that can be used to achieve better lives for people across the world [19].

Internationally, countries need to meet the 0.7% GDP aid commitment. International taxation needs to be considered and debt cancellation accelerated in order to redistribute wealth more equitably. Nationally the state has a role in regulating and controlling the market. Progressive taxation and universal access to health and social services can help reduce poverty [7]. As shown there is already a clearly defined alternative to the neo-liberal approach. However even if there was not human ingenuity could surely find a solution to this problem. If the human race can organize itself to enable travel and communication across the globe it can find a way to ensure everyone in the world has access to the necessities of life. Poverty is a political choice not an inevitability [2].

It is right that the world responds so efficiently and passionately to crises like the Haitian earthquake but if this response is based on horror at life needlessly wasted then our response to the lives disabled and destroyed by poverty should be amplified many times over. If governments’ commitment to a shared humanity is to be more than empty words then they need to act with the same passion and sense of urgency in the fight to end poverty as they have in the aftermath of the earthquake. This is particularly poignant considering Haiti’s long history of deprivation. Acting in the aftermath of a natural disaster is like putting a band-aid on what was already a gaping wound. A survey conducted in Haiti between 1999-2000 found that 67% of the population was living in poverty. Between 1996 and 2000 infant mortality rose from 73 to 80 per 1000 live births, an increase associated with increases in poverty, HIV and inadequate health services [20]. Increased investments should have been made long ago in infrastructure and development to alleviate the desperate poverty and silent suffering of Haiti’s people.

If we are to preserve our integrity as individuals and as nations we need to fight for the silent millions outside the gaze of the media who suffer under the weight of a global humanitarian crisis. We must be a voice for the voiceless victims of the unnatural disaster that is poverty.

Emily Wilson is a third year medical student at the University of Bristol
emsw123(at)hotmail.co.uk

References:

1. United Nations. The Declaration of Human Rights. Article 25. 1948. [Online] Accessed: 20/01/10 Available from: http://www.un.org/en/documents/udhr/

2. Gordon, D. (2004) Poverty, Death & Disease, in Hillyard, P., Pantazis, C., Tombs,

S. and Gordon, D. (Eds) (2004) Beyond Criminology: Taking Harm

Seriously. London, Pluto.

3. Jones G. et al (2003) How many child deaths can we prevent this year? Lancet 362: 65-71

4. Gordon D. (2009) Poverty, Death and Disease: and introduction to inequalities and health. Presented on The International Health Course. Bristol University.

5. Collier P. (2008) The Bottom Billion: Why the poorest countries are failing and what can be done about it. Oxford. Oxford University Press.

6. People’s Health Movement, Medact, Global Equity Gauge Alliance. Global Health Watch 2; 2008 [Online] Accessed: 20/01/10 Available: http://:www.ghwatch.org/ghw2/ghw2pdf/ghw2.pdf

7. CSDH (2008). Closing the gap in a generation: health equity through action on the social

determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.

8. Townsend P. and Gordon D. (2002) The Human Condition is Structurally Unequal in Townsend P. and Gordon D. (eds) World Poverty: New policies to defeat and old enemy. Bristol. Policy Press.

9. Gloyd, S. (2004) ‘Sapping the poor: the impact of structural adjustment programs’ in M.Fort, MA Mercer and O. Gish (eds) Sickness and Wealth: the corporate assault on global health. Southend Press.

10. World Bank (2010) World Development Report 2010: Development and climate change. Washington. World Bank.

11. Hofrichter R. (2003) ‘The Politics of Health Inequality’ in Hofrichter R. (eds) Health and Social Justice: politics, ideology and inequality in the distribution of disease. San Francisco, John Wiley & Sons.

12. Oxfam (2000) Agricultural trade and the livelihoods of small farmers: discussion paper for DFID. Oxfam GB Policy department. [Online] Accessed: 15/01/09 Available: http://www.oxfam.org.uk/resources/policy/trade/index.html

13. Sachs J. (2005) The End of Poverty: Economic Possibilities for Our Times. London, Penguin Books.

14. People’s Health Movement, Medact, Global Equity Gauge Alliance. Medicines in Global Health Watch ; 2005-06. [Online] Accessed: 20/01/10 Available from: http://www.ghwatch.org/2005_report.php

15. Oxfam (2002) Milking the CAP: How Europe’s dairy regime is devastating livelihoods in the developing world. Briefing Paper 34. [Online] Accessed: 15/01/09 Available:

http://www.oxfam.org.uk/resources/policy/trade/downloads/bp34_cap.pdf

16. Baker D. Financing drug research: what are the issues? Washington DC, Center For Economic and Policy Research; 2004b.

17. Stiglitz J and Charlton A. (2005) Fair Trade for All: how trade can promote development. Oxford. Oxford University Press.

18. Wilkinson RG and Pickett KE (2009). The Spirit Level: Why more equal societies almost always do better. Penguin.

19. Sen (1999) Development as Freedom. Oxford. Oxford University Press.

20. Pan American Health Organization. Basic Health Indicator Database. [Online] Accessed: 20/01/10 Available from: http://www.paho.org/English/DD/AIS/cp_332.htm

Skulls of some of the victims of the Khmer Rouge regime are now kept in a commemorative Buddhist ’stupa’ at the Killing Fields of Choeung Ek, Phnom Penh.

Introduction

Cambodia, a developing, post-conflict country, underwent cruel and dramatic reorganisation by the Khmer Rouge (KR) between 1975 and 1979 in attempt to convert the country into a Maoist peasant-dominated agrarian society. Although the issue of how many died in this traumatic conflict remains controversial, there has been an estimated 1.5 to 3 million deaths (20-40% of the Cambodian population) [1, 2] and millions others exposed to slave labour under harsh conditions [3]. These atrocities committed by the KR are documented as ‘genocide’ [3]. Amongst the crimes committed were massive killings and starvation, large-scale population transfers, forced labour on collective farms and a near destruction of the school system. One of the interesting theories which sparked the start of the regime was the secret bombing campaign in the final stages of the US-Vietnam war. This plan was masterminded by former US Secretary of State Henry Kissinger and former US president Richard Nixon, involving 240 000 tons of bombs being dropped in Cambodia, which was 50% more than the Allies dropped on Japan [4]. The KR used this as propaganda for their radical policies.

Photos of the victims of the genocide at Tuol Sleng. Most were buried in unmarked graves.

Many studies have reported post-traumatic stress disorder (PTSD), somatic symptoms and disability amongst the survivors of this ordeal, but such results were based on samples drawn from specific groups such as refugee camps [5, 6]. Although the effects of PTSD as a whole in the Cambodian population still remains somewhat ambiguous, the evidence of the emotional impact of the KR regime has been identified and documented.

There has been an immense impact of this ‘genocide’ on the Cambodian people. In reality, this should be compared to the likes of the infamous killings in Rwanda and Yugoslavia. This article is a factual account of the epidemic of psychiatric health problems and the long and troubled wait for justice and mental healthcare by the Cambodians after the KR.

Sequence of Traumatic Events

After the Vietnamese invasion in December 1978 which caused the downfall of KR, millions fled to the Thai-Cambodian border [6]. In 1982, over 350 000 Cambodians were officially classified as displaced persons, and were receiving assistance from eight camps under the United Nations Border Relief Operation [7]. In a study conducted by Mollica et al, more than 83% of all victims reported experiencing a lack of food and water, and forced labour, ill health without medical care, brainwashing, lack of shelter, and forced separation from family under the KR regime [5]. More than half experienced the murder of a family member or close friend, being close to death themselves, isolation from others, and forced evacuation from their homes [5]. Smaller but significant numbers reported torture (35.8%), rape or sexual abuse (17.0%), serious injury (17.8%), beatings to the head or other parts of the body (17.8-26.0%), near drowning (26.7%), loss of consciousness (15.1%), and near suffocation (13.1%) [5]. From 1980-1990, these brutal acts were transformed to various problems experienced while living in a refugee camp, such as inadequate food, water and shelter, bombing and shelling, armed robbery, and domestic violence [5].

Children held captive at the Tuol Sleng prison were beaten against this tree. There were other trees in the compound which had loudspeakers playing music to drown out cries of the victims during the regime.

Mental Health Issues after KR

Unlike many countries worldwide, Cambodia was not challenged by a deinstitutionalisation of their mental health facilities, but the inadequate redevelopment of formal mental health infrastructures [8]. During the KR rule, the killings of the two remaining psychiatrists in the whole country left Cambodia without any psychiatric care, which led to dependency on alternative therapy for spiritual healing [9]. To make matters worse, many were left with the unfortunate legacy of psychological as well as somatic symptoms for many years after the KR (Figure 1). Some survivors could not decide if life was worth living, resulting in 5.6% attempting suicide while living in the refugee camp [5].

Figure 1: Self-reported health problems amongst Cambodians in the Thai-Cambodian Border Camps [5]

Of the 13 symptoms described by Mollica et al [5], the highest reported symptom was ‘bebotchit’, a deep sadness within oneself, caused by unfortunate events which lies so deeply within a person that it can go unnoticed by others. Additional depressive symptoms experienced by this same group were srongot srangat, a visible sadness far worse that bebotchit, hopelessness, worthlessness, and suicidal tendencies. Recent studies on Cambodian immigrants in the US based on the Hopkins Symptom Checklist-25, which measures symptoms of anxiety and depression, showed that 55.0% scored with major depression based on the DSM-III-R criteria [10]. In addition, many Cambodians with depression presented with somatic symptoms, such as frequent headaches, weakness, dizziness, poor appetite, and cold hands or feet [5], and some already had existing psychological symptoms of depression. Of these somatic symptoms, headaches and dizziness were the commonest. They are believed to be a cultural expression of emotional distress and are associated with chief complaints of psychiatric illness in Cambodian adults [11]. Furthermore, the Harvard Trauma Questionnaire for Cambodians living in the US found that the prevalence of many of these individual symptoms may constitute the Western diagnosis of PTSD [12].

With an aim to improve and redevelop the mental health services in Cambodia, a Mental Health Subcommittee (MHSC), which is an extension of the Ministry of Health (MoH) Coordinating Committee assisted by the World Health Organisation (WHO), was formed. The MHSC, chaired by an influential Khmer psychiatrist, include other Khmer psychiatrists, WHO officials, and western expatriates from international non-governmental organisations (NGOs). Although the MHSC has contributed to mental health services, its resources remain limited because they relied heavily on external funds from NGOs and the MoH failed to allocate adequate finances [13]. Regardless of these complex factors, in 2002, human resources have identified 350 mental health-care providers: 20 psychiatrists, 20 psychiatric nurses, and 215 psychiatric clinical psychologists. This achievement offers some degree of primary and acute mental health care facilities, both public and private, with assistance primarily from NGOs [8]. Unfortunately, there are no professionally-trained psychiatric social workers or occupational therapists [8].

Getting Away with Genocide

Amongst the many instruments used by the Khmer Rouge to torture and interrogate prisoners at the notorious Tuol Sleng Security Prison (S-21).

Cambodia is a complex case study of double standards and selectivity of international humanitarian law [14]. After a series of long drawn-out negotiations from 1979 to 2003, a special tribunal, sponsored jointly by the United Nations and the Kingdom of Cambodia (‘Extraordinary Chambers in the Courts of Cambodia’ or ‘Khmer Rouge Trials’) was finally empanelled in order to try the senior leadership of the KR [14]. In the last three years, 5 top leaders have been arrested for pre-trial hearings [15]. On the other hand, Pol Pot, who was guilty of some of the worst crimes in the twentieth century, cheated justice with his death in 1998. In contrast to the Yugoslavian and Rwandan conflicts, the initiations for these trials have taken a longer time. Some have speculated that the delay was due to previous support of the KR by other governments, including China, Singapore, Thailand, the US and the UK [14]. This initial hesitance was due to concerns about rebuilding a shattered nation [14].

Finally, it is important to consider the effects of the tribunal on the Cambodian people as they are directly involved in these trials. The stated primary goals of the trials are to assess the guilt or innocence of the accused in order to decide on suitable punishment for the guilty. By holding these tribunals, both anger and desire for revenge which are associated with the prevalence and severity of PTSD in Cambodians may be reduced [16]. Some have suggested that bringing the guilty to justice may indirectly lessen feelings of vengeance in a country of previous widespread violence [17]. In contrast, others have suggested that the trials may provoke an increase in the prevalence and severity of PTSD by ‘retraumatizing’ the survivors [18].

Conclusion

Regardless of whether PTSD is dealt with by mental health care providers or in a form of a tribunal bringing criminals to justice, it is not clear that psychological scars left on Cambodians by the genocide will heal anytime soon. Some analysts have reported that none of the top communists will ever be put on trial due to fear of shaking the political stability the country is struggling to achieve [14]. Others, such as the former executive director of the Khmer Institute of Democracy, have criticised that the government is ‘buying time’ until all the top leaders die [14]. This event raises important questions for the advocates of human rights: Why did the world wait for a quarter of a century before these criminals stood in court? Why should Cambodia be deprived of international humanitarian law which should be applied justly to every country in the world? Furthermore, these trials are arguably lacking in legitimacy because of the narrow focus on KR officials during the period of the genocide, while ignoring the role of officials from other countries who also committed crimes against humanity in Cambodia, such as Henry Kissinger.

Despite the pressures and obstacles faced now, there is a hope amongst many. By raising awareness of this genocide which left millions dead and even more with chronic mental health issues, the Cambodian people cannot be cheated again and all the living KR co-conspirators will ultimately face up to justice.

Christine Chew is a 4th year medical student at the University of Manchester
christine.chew(at)student.manchester.ac.uk

References:

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2. Hannum H. International law and Cambodian genocide: the sounds of silence. Hum Rights Q. 1980; 11: 82-138.
3. Kiernan B. The Pol Pot Regime: race, power and genocide in Cambodia under the Khmer Rouge, 1975-79. 2nd ed. New Haven and London: Yale University Press; 2002.
4. Shawcross, W. Sideshow, Revised Edition: Kissinger, Nixon and the destruction of Cambodia. London, England: Hogarth; 1986.
5. Mollica R, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental status of Cambodians living in the Thai-Cambodia border camps. JAMA. 1993; 270: 581-586.
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17. Friedman M. The truth and reconciliation commission in South Africa as an attempt to heal a traumatized society. In: Shalev AY, Yehuda R, McFarlane AC, eds. International Handbook of Human Response to Trauma. New York, NY: Plenum Publishers; 2000: 399-411.
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