Maryam Zaky discusses an underreported aspect of violence in refugee camps and the impact it can have on the spread of HIV

Sexual and Gender based violence (SGBV), whilst a universal dilemma, is a well recognised problem arising within refugee camps and conflict settings. Camps can enhance violence due to the presence of various ethnic and socio-economic groups existing within these confined spaces. This causes tensions, which often spill into the community. (1) Forced sex increases the risk of HIV transmission by cutting and abrading, allowing the virus to cross the genital mucosa more easily increasing susceptibility (of women and especially young girls) to HIV. (2) However, Crisp and Jacobsen argue that the association of SGBV with camps does not always hold and that camps often offer greater security to refugees and to the host community (HC). (3) Furthermore, Spiegel and Colleagues provide arguments and evidence highlighting the difficulties in asserting the blame for HIV prevalence on the presence of refugee camps due to the practical hardships of accurately estimating this, namely ethical issues regarding HIV testing and the stigma surrounding HIV. (4) (more…)

Mandip Jheeta, a Birmingham Graduate, writes about neonatal mortality and how the international health community could pull together to to tackle the issue. 

Every year, an estimated 4 million babies die in the neonatal period; the first 4 weeks of life. 99% of these deaths arise in low and middle-income countries. (1,2) The highest death rates are mainly in sub-Saharan Africa, which has 14 of the 18 countries with neonatal mortality rates (NMRs) above 45 per 1000 livebirths. Furthermore, data from 20 sub-Saharan African countries show consistently higher NMRs for those in the poorest quintile compared to the richest. (1)

Currently, coverage of interventions is low, progress in scaling up is slow, and inequity is high regarding neonatal survival in sub-Saharan Africa. (3) Health outcomes and health systems, particularly for maternal, neonatal and child health, are consistently inequitable: More and higher quality services are provided to the rich, who need them less than the poor who are unable to obtain them. (4,5,6,7) In the absence of policies for health systems to address the needs of the poorest, most disadvantaged and vulnerable populations, this trend is likely to continue. (4,6)

There is clearly a need to improve the current situation, but will it happen?

In low- and middle-income countries, preventing newborn deaths has often not been a focus of child survival or safe motherhood programmes. (1,2) Consequently, progress has lagged behind. Perhaps more significantly, the need for health policy or reform is widely observed to be a poor predictor of whether it will be implemented. (5,6,7,8) This is because health policy making is mainly observed to be a ‘messy’ process, which is influenced by political factors to varying degrees.

In recognition of this complex policy making environment and the need to improve neonatal survival and equity, this article aims to suggest ways to:

• Get policy makers interested in and strengthen political will for improving neonatal survival;
• Improve equity in neonatal survival strategies and the wider health system;
• Increase the capacity of policy makers to make significant improvements in neonatal survival, and increase the capacity to improve equity.

Raising interest

A degree of broad-scale and multisectoral collaboration in the sub-Saharan African region is likely to be necessary to effectively address the main causes of neonatal death, particularly poverty. Collaboration may have the potential to generate ‘political economies of scale’ of raising interest and influence on health policy. Such attention is essential for an area that has often been neglected by policy makers. (6,7,9)

The Lancet Neonatal Survival Series (1,3,9,10) addresses issues of neonatal survival, and represents the most thorough and useful evidence and support for policy formation. The series recognises varying contexts, and identifies 16 interventions with proven efficacy for improving neonatal outcomes in low- and middle-income countries. Considerable recommendations are also made for how to plan and build support for realistic neonatal programmes. For example, it highlights how early successes in averting neonatal deaths are possible, even with high mortality and weak health systems. (10)

One collaborative suggestion may be to formalise the recommendations of current evidence on neonatal survival, for example from the Lancet Neonatal Survival Series and elsewhere, into an integrated policy framework for the sub-Saharan African region. A framework promoting, informing and suggesting neonatal survival strategies may be feasible and appealing for policy makers and key stakeholders, rather than a ‘one-size fits all’ approach.

Other proposals for raising the interest and will to improve neonatal survival include adopting NMR as an indicator for Millenium Development Goal 4 (a commitment by the international community to reduce mortality in children younger than 5 years by two-thirds between 1990 and 2015, and encouraging countries to produce and publish plans of action to reach their neonatal targets. (9)

Promoting equity

Various strategies exist to promote equity in health systems:

• Establishing goals and policies for improved coverage in disadvantaged populations, rather than entire populations; (4)
• Modifying existing goals towards disadvantaged groups. (4) For example, in Tanzania ‘raising attended deliveries in the entire population’: from 50% in 2000 to 80% in 2010′, can be adjusted to ‘raising attended deliveries in the 48% of the population below the national poverty line’: from 37% in 1999 to 80% in 2010; (4)
• Using appropriate techniques where pro-poor policies have worked successfully in other countries, and encouraging collaboration and dissemination of experiences; (4,6,7)
• Implementing primary and preventative care strategies, which tend to be less regressive than higher care levels; (4,5,7) Contracting or encouraging services in the not-for-profit private sector (which are often very significant in sub-Saharan Africa) to develop pro-poor strategies or performance indicators, particularly those organisations that may be amenable to such objectives (e.g church health services, mission organisations, charitable NGOs); (4)
• Empowering poor clients to have a more central role in health system design and operation, to counterbalance the influence of the rich; (4,5,6)

Improving the political climate

Strategies also exist to improve the political climate towards promoting equitable neonatal survival policies:

• A greater dissemination of information on neonatal outcomes, inequalities and inequities. Such policy-relevant information may be a force for change at national, regional and community levels; (3,5,6,9)
• Making solutions and interventions broadly inclusive, but disproportionately benefiting the target or deprived group should help to build political support by not excluding other interest groups. (5,6) Effective interventions may, however, require specific targeting, and social and cultural tailoring; (7)
• The support of influential professional groups should be sought and cultivated in initiating significant policy changes; (5,7)
• Having a strong evidence base for interventions; (3,6,9)
• A phased management plan, of initial short-term gains, followed by strategies for medium term gains, and then long-term gains, to build momentum and progressively accumulate political consensus. (3,5,6,9)

Looking forward

Collaborative efforts in the sub-Saharan Africa region have the potential to increase the low coverage of current interventions, speed up the slow progress in scaling up care, and improve the high inequity with regard to neonatal survival. Consideration and understanding of the complex policy making environment is essential to reversing this trend, and should be a part of all health initiatives. Such understanding is necessary to successfully place neonatal survival on the policy agenda, and implement effective and sustainable neonatal survival strategies.

Mr Mandip Jheeta

Medicine MBChB 2002-08

University of Birmingham

Birmingham, UK

mandipjheeta@gmail.com

References

• (1) Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet. 2005 365(9462): 891-900
• (2) World Health Organisation. Chapter 5: Newborns: no longer going unnoticed; in World Health Organisation. The World Health Report 2005: Making every mother and child count. 2005. Geneva: World Health Organisation; 2000, 79-101
• (3) Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N, Paul VK; Lancet Neonatal Survival Steering Team. Systematic scaling up of neonatal care in countries. Lancet. 2005 365(9464): 1087-98
• (4) Gwatkin DR, Bhuiya A, Victora CG. Making health systems more equitable. Lancet. 2004 364(9441): 1273-80
• (5) Cassels A. Health sector reform: key issues in less developed countries. J Int Dev. 1995 7(3): 329-47
• (6) Birdsall N, Hecht R. Swimming against the tide: strategies for improving equity in health (working paper). World Bank; 1995 [cited 2006 May 9] Available from http://www-wds.worldbank.org/servlet/WDS_IBank_Servlet?pcont=details&eid=000009265_3961019111234
• (7) Dmytraczenko T, Rao V, Ashford L. Health sector reform: how it affects reproductive health. Population Reference Bureau (PRB); 2003. [cited 2006 May 9]. Available from http://www.phrplus.org/Pubs/HealthSectorReformColor.pdf
• (8) Collins C, Green A, Hunter D. Health sector reform and the interpretation of policy context. Health Policy. 1999 47(1): 69-83
• (9) Martines J, Paul VK, Bhutta ZA, Koblinsky M, Soucat A, Walker N, Bahl R, Fogstad H, Costello A; Lancet Neonatal Survival Steering Team. Neonatal survival: a call for action. Lancet. 2005 365(9465): 1189-97
• (10) Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L; Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005 365(9463): 977-88

Sarah Nathaniel, Stephanie Wells and Abi Perini discuss healthcare provision for the homeless and their personal experience in this field as medical students. 

Two men sit on a park bench. A middle-aged man with eyes fixed to the floor holds a cigarette in the fingers of his right hand and in his left he grasps a half empty bottle of cider. He smells terrible and his beard is matted with the remains of last night’s dinner.  At his feet lie a bundle of carrier bags, the sum total of his possessions. The other man is younger, clean shaven with short well kept hair and the aroma of aftershave. He is wearing an open necked shirt with a pair of smart trousers and sits reading a copy of The Times drinking his morning coffee. At first glance it may appear that these two men belong to completely different worlds, but they both have one thing in common; they are both homeless.

Judgement, we are all guilty of it. For most of us, the tramp on the bench would be what automatically springs to mind when thinking about homelessness. How many of us if we were sitting opposite would have guessed that both of these men were homeless? Personal encounters with homeless individuals, views held by our peers and the typecast portrayal of homeless characters by the media, all contribute to the formulation of our own ideas and opinions about homeless people. But what does it actually mean to be homeless? How much of the homeless stereotype that we believe to be true is actually true? And what is the significance of all of this to medical students and other healthcare students? (more…)

Jasmine Marshall discusses the important but neglected problem of child injury. This article comes from  from a winning project report she wrote for an intercalated BSc in International Health at University College London

Injuries are the leading cause of death for European children under 14 years of age, killing an estimated 28,000 every year (1) and disabling many more. There are striking differences within the European Region. The death rate from injuries, poisoning, and violence in Central and Eastern Europe and the Central Asian Republics is nearly 5 times higher than in Western Europe. (2) A 1998 report by the European Centre on Health in Transition Countries (ECOHOST) showed that injuries accounted for much of the difference in child mortality between east and west. It concluded that this problem had been overlooked by national and international policy makers, and required urgent attention. (3)

Unfortunately, a decade later, “injuries and violence in children [still] present a major, tangible and preventable burden to these societies” (3) and the east-west gap remains. To understand why this is the case we need to consider the eastern European region’s history, its long term health system development and the current economic and political context.

Historical Legacy
Recent Communist rule is a common feature of the countries in Central and Eastern Europe and the Central Asian Republics. The egalitarian-authoritarian political system stifled the mechanisms through which people instigate change, for example campaign groups pressing for higher safety standards. Weak public participation in the policy process, together with a centrally-controlled media (4) probably contributed to a lack of ownership of childhood injuries as a policy issue.

The Soviet Union “Semashko model”, of state-owned centrally-controlled health services was well staffed, but poorly funded and under-resourced. It focused heavily on treating communicable disease but public health organizations were weak (5) and health professionals had little knowledge of preventative medicine and health promotion. This was exacerbated by their isolation from the global epistemic community during the Cold War. The state guarded what statistical and epidemiological data there was available, leaving health professionals unclear about the magnitude of many threats to health. This legacy of inadequate data means that even now, health professionals and academics struggle to define the nature and scale of childhood injuries, making it difficult to draw attention to the issue.

Following the collapse of the former Soviet Union, countries entered a period of economic and political transition. Unemployment, poverty, social stress and increased substance abuse (6) led to higher rates of injuries and violence, particularly amongst low socioeconomic groups.  Children living in poverty are at greater risk of sustaining injury, (7) yet they are largely unable to advocate for themselves, especially at the population level. To design effective policy, it is important to facilitate collaboration between families, (particularly socially-excluded parents) health professionals, and public bodies.

Today’s Challenges
Injury prevention is cost-effective; however a lack of awareness of the scale and impact of childhood injuries stifles financial investment in policy. The health sector has multiple responsibilities and is subject to numerous demands. To convince the policymakers who allocate resources that injury prevention is an important priority, the economic burden of childhood injuries must be carefully assessed.

Although the overall burden of childhood injuries within Central and Eastern Europe and the Central Asian Republics is high, there are some notable sub regional variations in 0-14 mortality rates which appear to reflect broader differences in social and political stability following transition. Child mortality is highest in countries such as Kazakhstan, the Russian Federation and Belarus, with a recent history of conflict or restrictive social and political environments and a rising level of alcohol consumption and violent crime.

A survey of the WHO European region (8) concluded that few low- and middle-income countries (predominately those in Central and Eastern Europe and the Central Asian Republics) had “developed an adequate structural response” to reduce the burden of injuries. The most promising commitment comes from the European Union (EU) member states, where the political and financial environment appears to have facilitated a policy response. Poland, Estonia, Hungary, Latvia, Slovakia, Romania and Bulgaria, receive financial and technical support from the European Community which helps to plan, research and implement national child safety interventions. Interestingly, prior to EU accession Poland, Hungary and Bulgaria, were already bridging the east-west mortality gap, and it is possible that countries aspiring to EU accession may have reduced child mortality from injuries by aligning themselves with EU safety standards.

Elsewhere in the region, the environment has not favoured a strong, co-ordinated policy response, and childhood deaths from injuries have had low visibility. Although childhood injury policy should be considered in a wider context of political, economic and social reform, a number of measures that might improve visibility and ownership of the issue and capacity within the health sector could also help to reduce the burden.

Firstly, to increase the visibility of childhood injuries, the WHO and other organisations could help to develop detailed data collection systems. National and international media could use the data to frame the issue to a variety of stakeholders, raising awareness and stimulating public debate.

Secondly, the health sector should take ownership of the problem whilst collaborating with ministries of Education, Transport and Social Policy to integrate injury prevention into existing schemes such as WHO safe communities’, healthy schools programs, and environmental health initiatives. Civil Society Organisations (CSOs) can act as a bridge between the state and communities. The numbers of CSOs in Central and Eastern Europe have risen dramatically during transition. Many receive foreign funding, with the Open Society Institute and its national Soros Foundations playing key roles. However donor priorities strongly influence the type of activities they engage in. Regional and national public health conferences under the aegis of a global health authority such as UNICEF could be used to engage local CSOs.

Thirdly, building public health capacity and encouraging training for health professionals should improve data interpretation and its presentation to stakeholders, policy makers and the media. Hungary has recently developed a new postgraduate training program in public health medicine which may serve as a model for other countries.

The countries in Central and Eastern Europe and the Central Asian Republics have undergone a tumultuous period of political and economic transition. This has, in part, contributed to the high burden of childhood mortality from injuries, particularly when compared with Western European counterparts. Continuing development may lead to a gradual reduction in the number of injury related child deaths. This is not sufficient. With cost effective interventions, already successfully pioneered elsewhere in the world, this crucial and neglected aspect of child health could be actively addressed today. The pivotal first step in these countries is to raise childhood injuries onto the health policy agenda.

Jasmine Armour-Marshall BSc
International Health. Centre for International Health and Development,
Institute of Child Health, University College London
30 Guilford Street, London, WC1N 1EH, UK.
 jasmine.marshall@ucl.ac.uk

I would like to thank Ingrid Wolfe, Martin Mckee, Bhanu Williams and the tutors at CIHD, in particular Mike Rowson, for their expertise and support. I would also like to acknowledge the Goldberg Schachmann & Freda Becker Memorial Fund for financially supporting me through this BSc

(1) World Health Organisation (2006) A handbook: planning to protect children from hazards, The Children’s Environment and Health Action Plan for Europe, Geneva

(2) World Health Organisation European Health For All mortality database (WHO-HFA), version 2006

(3) European Centre on Health of Societies in Transition (ECOHOST) (1998). Childhood injuries: A priority area for the transition countries of Central and Eastern Europe and the Newly Independent States, London School of Hygiene and Tropical Medicine, London

(4) Van Hoven B. (2004) Europe Lives in Transition, Pearson Prentice Hall, Essex, England.

(5) McKee M. Bojan F. Normand C. (1993). A new public health training in Hungary. European Journal of Public Health: 3: 58-63

(6) Carlson P. Vagero D. (1998). The social pattern of heavy drinking in Russia during transition. European Journal of Public Health: 8(4): 280-85

(7) Kendrick D. Marsh P. (2001). How useful are sociodemographic characteristics in identifying children at risk of unintentional injury? Public Health: 115 (2): 103-107

(8) Sheilds N. Sethi D. Racciopi F. Aguirre I. Y. Baumgarten I. (2006). National Responses to Preventing Violence and Unintentional Injuries: WHO European Survey, The World Health Organisation, Geneva 

Blood donation is an important area of global health. According to the World Health Organisation (WHO), over 81 million units of blood are donated globally; however, only 45% of this blood comes from developing countries, which is home to about 80% of the global population. (1) Additionally, both developing and developed countries have issues with the security of their blood banks in their quest to safeguard the integrity of their blood supplies. In the developing world the main problem lies in the prevalence of paid or mercenary donors while in the developed world, the issue revolves around the exclusion of certain groups of potential donors, in particular, men who have sex with men (MSM).

Increasing Blood Donation & World Blood Donor Day

Most blood donations in the ‘developed’ world are voluntary and unpaid. However, the majority of blood donations in the ‘developing’ world are from paid donors or from family members of those who may require a transfusion. (1) This is not ideal, as voluntary unpaid donors are the safest source of blood and are the least likely to transmit blood-borne infections such as Human Immunodeficiency Virus (HIV) and the Hepatitis viruses. (3) Voluntary blood donors are not pressured into donating blood and are less likely to hide information about their health status or behaviour which would make them ineligible to donate blood.

In order to motivate countries to encourage blood donation from unpaid volunteers, World Blood Donor Day (WBDD) was set up on June 14, 2005, in commemoration of the birthday of Karl Landsteiner, who discovered the ABO blood group system. (3) The aims of WBDD are to increase awareness of the importance of voluntary blood donation, to encourage more people to become regular blood donors and to celebrate the individuals who voluntarily donate blood. (3)

This year, the fourth WBDD was celebrated in the United Arab Emirates (UAE). The UAE was the first gulf country to ban importation of blood in 1984, after the discovery of HIV/AIDS. (2) Within a few years, its Government established a national blood transfusion programme which encouraged voluntary unpaid blood donation. Within 16 years, the country managed to go from 0% voluntary donations in 1990 to 97.6% voluntary donations in 2006. (2) The programme has been successful because it incorporated a supportive culture of voluntary blood donation and used the media to raise awareness.

On WBDD itself, various speeches and activities were conducted at the Emirates Palace in Abu Dhabi and the Emirates Towers, Dubai. A list of the guest speakers can be seen in figure 1.
 

The day also involved the handing of awards to voluntary blood donors, governmental and private organisations supporting the aims of WBDD and the organising committee. The WBDD Flag was also handed over to the Australian Ambassador.

Protecting the Purity of Donated Blood

To ensure that only safe blood is donated, it is common practice to ban groups who are at high risk of carrying blood borne infections such as prisoners, prostitutes and individuals who have returned from travelling within malaria-infested zones. However, such policies have received criticism for their exclusion of MSM from donating blood. Most countries, e.g. UK, USA and most of Europe, have a lifetime exclusion of MSM. Others, e.g. New Zealand, Australia and Japan, exclude MSM donors for a defined period of time, ranging from one to ten years since their last sexual encounter with another man. (4,5) Consequently, it has been argued that the lack of uniformity with regard to MSM donors highlights that social and cultural values, rather than scientific evidence, form the basis of the ban. (5)

Critics of the restrictions on blood donation by MSM maintain that advances in testing and screening have reduced the risk of transmission of blood-borne diseases (notably HIV). (5) Initial tests for HIV involved looking for the presence of antibodies to the virus. However, there is a ‘window period’ of three to six months before the body produces these antibodies. This potentially allows some individuals to unintentionally pass on the disease even though they have a negative test result. More recently developed tests look for HIV itself and its genetic components, such as Nucleic Acid Amplification Testing (NAAT). These tests are more sensitive and have a window period of approximately twelve days. (6) As of 2007, the UK has implemented NAAT screening for HIV; however, it is not an effective test for other blood borne pathogens. Therefore, further tests are required to ensure donated blood is disease-free. (5)

Another criticism of the blanket ban on MSM donation is that it excludes men who solely engage in safe sexual practices (such as mutual masturbation or oral sex). These men are at a very low risk of contracting blood-borne infections. With blood shortages common within the UK National Blood Service, critics argue that such healthy donors should not be excluded from donating blood. (5) However, the UK National Blood Service maintains that to differentiate between MSM who engage in safe sexual practices and those with risky sexual habits would require identifying and taking detailed sexual histories from MSM donors, which would be difficult to implement with over 7000 donors a day. (4,5)

Various recommendations have been made by opponents to the MSM ban. One suggestion is that the UK National Blood Service implements a policy similar to Australia and allow MSM to donate blood one year after their last sexual contact. (4,5) Models used by the UK National Blood Service, estimate that such a policy would result in an increased risk of HIV-infected blood entering the blood service by 60% and an increase of less than 2% of non-infected donations. (4,7) However, this statistic was calculated five years ago and requires updating due to the development of more accurate blood screening.

Conclusion

The main issues with blood donation involve the security and quantity of blood donated. The quantity of blood in the developing world is a considerable problem because of the lack of voluntary donors. In addition, the security of blood is at risk due to the prevalence of paid or mercenary donors who have the financial incentive to be dishonest. The quantity of blood donated in the developed world is also problematic due to policies in place to maintain the security of blood donated, in particular the exclusion of MSM from blood donation. This, in a way, draws comparison between MSM and paid donors who are considered unsafe, and raises questions about the fairness of the exclusion of MSM from donating blood.

Shawn Ellis, 3rd year medical student
Brighton Sussex Medical School
S.D.P.Ellis@bsms.ac.uk
 

References

1.  WHO.  Blood  Safety.  [Online]  2008.  [Cited:  05  07  2008.]  http://www.who.int/topics/blood_safety/en/.  

2.  WHO.  world  blood  donor  day.  [Online]  2008.  [Cited:  05  07  2008.]  http://www.thelancetstudent.com/wp-admin/www.who.int/worldblooddonorday/en.  

3.  Day,  World  Blood  Donor.  About  World  Blood  Donor  Day.  [Online]  2005.  [Cited:  05  07  2008.]  http://www.wbdd.org/index.php?id=24.  

4.  Transplant,  NHS  Blood  and.  Exclusion  of  men  who  have  sex  with  men  from  Blood  Donation  Position  Statement.  [Online]  2008.  [Cited:  05  07  2008.]  http://www.blood.co.uk/pdfdocs/position_statement_exclusion.pdf.  

5.  Does  Blood  Discriminate?  K,  Phillips.  London  :  The  Lancet,  2008,  Vol.  371,  pp.  1983-1984.  

6.  Detection  of  HIV-1  and  HCV  infections  among  antibody-negative  blood  donors  by  nucleic  acid-amplification  testing.  Stramer  SL,  Glynn  SA,  Kleinman  SH,  et  al.  s.l.  :  New  Eng  J  Med,  2004,  Vol.  351,  pp.  760-68.  

7.  Evaluation  of  the  de-selection  of  men  who  have  had  sex  with  men  from  blood  donation  in  England.  Soldan  K,  Sinka  K.  s.l.  :  Vox  Sanguis,  2003,  Vol.  84,  pp.  265-73.   

Recently I attended a World Model United Nations (MUN) conference in Puebla, Mexico. Implemented by Harvard University in 1991, it aims to realistically simulate the proceedings of the United Nations, whilst bringing together delegates across the world to debate and discuss issues of global significance. All delegates were assigned to represent a particular country in order to participate in a specific UN committee during the conference. I represented Australia’s position in the WHO committee and the topic of discussion was Traditional/Complementary Medicine (TM/CAM). [1] Having spent 5 years in medical school without much exposure to this issue, the insights I gained from this experience were invaluable, particularly on the significance of TM/CAM in the developing world and its potential repercussions.

     Figure 1: Use of TM for primary health care in some developing countries. Source: compiled from government reports to WHO (WHO Traditional Medicine Strategy 2002-2005, p. 9)

TM/CAM is used extensively in the developing world as demonstrated in figure 1. This is unsurprising as data from WHO shows that amongst the one-third of the world’s population who lacks regular access to essential allopathic medicine, over half belongs to the most impoverished parts of Asia and Africa. [2] The two main determinants for TM/CAM popularity in the developing countries are hinged upon its relative accessibility and affordability to allopathic medicine. In Tanzania, Uganda and Zambia, the ratio of TM practitioners to population is 1:200-1:400 which contrasts starkly with the availability of allopathic practitioners, where the ratio is approximately 1:20000 or less. [3]

Such patterns of healthcare resources distribution serves as a crucial reminder to any global efforts in stemming developing world diseases. For example, for malaria eradication efforts to be effectively implemented, it will have to take into account the local health behaviours which mostly rely upon TM/CAM. Surveys conducted by the WHO Roll Back Malaria Programme in 1998 demonstrated that in Ghana, Mali, Nigeria and Zambia, more than 60% of children with high fever were treated at home with herbal medicines. [4-7] Moreover, the cost for malaria treatment with herbal medicines is considerably cheaper than other forms of health care (refer figure 2). In Ghana, Kenya and Mali, research has shown that a course of pyrimethamine/sulfadoxine antimalarials can cost several US dollars yet total out-of-pocket health expenditure in Ghana and Kenya is only around US$6 per capita per year. This low affordability of chemical drugs thus makes TM the only viable option for such populations.

    Figure 2: Comparison of malaria treatment in Ghana.  Source: adapted from Ahorlu C et. al., 1997 [8]

Nevertheless, safety issues inevitably arise with TM/CAM, as parallel standards and methods for evaluation are currently non-existent. For instance, from 1989-1991, 17 cases of cardiotoxicity following aconite herb intoxication were documented in Hong Kong public hospitals due to inconsistent quality control. [9] The safety and quality regulation is not as universally reliable as allopathic medicine because its practices have evolved within different cultures in different regions. Some TM/CAM providers may also hail from a cultural and philosophical background that differs radically from that surrounding the original development of a therapy, leading to misinterpretation and misapplication.

For many developed countries, there is a phenomenon of increasing TM/CAM popularity. In Australia, it has been demonstrated that about 68% population used TM/CAM at least once in 2005, relative to 52% in previous Australian studies. [10] TM/CAM use also parallels mainstream health care in some developed nations. In the USA, the total 1997 out-of-pocket CAM expenditure was estimated to be comparable to the projected out-of-pocket expenditure for all physician services that year. [11] The factors which give rise to this trend are essentially different from those of the developing world as TM/CAM usage is driven by personal autonomy and preferences as compared to dire social circumstances in the developing world. Emerging belief in holistic medicine, reduced tolerance of paternalism in conventional medicine and questioning of the approaches and assumption of allopathic medicine are some of the reported reasons for greater public use of TM/CAM in the developed world. [12]

If this trend of growing use in TM/CAM persists and increases across the world, looming challenges associated with this will involve more than just the medical paradigm of unsafe drugs and adverse reactions. The potential issues especially relevant to the developing countries also involve biodiversity conservation and intellectual property and patent rights for traditional medicine. These were the recurrent themes raised by the developing countries during our conference session which made me step beyond the developed world perspective as Australia to embrace these concerns more comprehensively.

In 2002, the WHO estimated that the worldwide market for herbal medicine was approximately US$60 billion. [13] With the tremendous expansion of international herbal product markets, especially from the developed world, there is great commercial profit to be derived from TM. In the USA, herbal sales increased by 101% in mainstream markets between May 1996 and May 1998 with the most popular herbal products including ginseng, Gingko biloba, garlic, Echinacea spp. and St. John’s wort. [14] As pharmaceutical herbal production requires large quantities of raw materials of medicinal plants, gathering TM faces sustainability issue due to the risk of over-harvesting. Countries in the African region may be affected negatively with loss of biodiversity if appropriate preventative measures are not in place. 200,000 of the world’s total 300,000 plants are found in Africa, with many used extensively in TM/CAM. [15] For example in 1997, it was mentioned that African potato was good for AIDS and after two years, this particular species was apparently wiped out in the Democratic Republic of Congo. [16] There are still many undiscovered possibilities with TM potency and efficacy in healthcare, thus its sustainability is pertinent in order to benefit mankind in the long run.

Existing intellectual property rights lack protection of traditional knowledge and resources. Although the raw materials of TM/CAM predominantly originated from the developing countries, there are many cases in which knowledge of TM has been appropriated, adapted and patented by scientists and industry, mainly from developed countries, with minimal or no compensation to the custodians of this knowledge and without their prior informed consent. An example is the turmeric patent which was granted in the USA in March 1995 for wound healing. However, in India, the wound-healing properties of turmeric powder are well known and have “been applied to the scrapes and cuts of generations of children”. [17] Therefore, it invited challenge from the Council of Scientific and Industrial Research of India which eventually invalidated this patent for lack of novelty. Nevertheless, many developing countries may find it highly costly and difficult to monitor for ‘biopiracy-patents’ without higher policy reforms in intellectual property rights. [18,19] Without appropriate protection granted to holders of traditional medicine knowledge, there may be little incentive for them to disclose the benefits of TM to the rest of the world. This may impact upon knowledge transfer thereby reducing access and impeding research efforts for global public health benefits. Paradoxically, the protection of TM is also likely to lead to an increase in cost and/or restrictions in the use of modern pharmaceuticals which would reduce access notably for those most dependent on it: the poor. [20]  

In conclusion, the developing countries not only face safety and quality issues of TM/CAM but also looming challenges of biodiversity and intellectual property rights in relation to the growing trend of TM/CAM usage globally. Thus, the most salient point I learnt from this MUN experience is to view global issues with greater receptivity towards understanding the implications to different parts of the world. Extending concerns towards the plight of those involved is particularly pertinent to reaching an equitable and just policy that will work best for all.

Ying Ying Liew, 5th year medical student
University of New South Wales
liew.yingying@gmail.com
           

1.  According to WHO Traditional Medicine Strategy 2002-2005, TM is a comprehensive term used to include both TM systems such as traditional Chinese medicine, Indian ayurveda and Arabic unani medicine, and to various forms of indigenous medicine. In countries where the mainstream health care system is based on allopathic medicine, or where TM has not been incorporated into the national health care system, TM is referred to as “complementary”, “alternative” or “non-conventional” medicine. Thus, Traditional/Complementary Medicine (TM/CAM) term is used to encapsulate all regions of the world.

2. Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review WHO.p.3 http://whqlibdoc.who.int/hq/2001/WHO_EDM_TRM_2001.2.pdf

3. Mhame, P. The Role of Traditional Knowledge (TK) in the National Economy: the Importance and Scope of TK, Particularly Traditional Medicine in Tanzania. Paper presented at UNCTAD Expert Meeting on Systems and National Experiences for Protecting Tradtional Knowledge, Innovations and Practices, 30 October-1 November 2000, Geneva.

4. Gyapong M et al. Report on Pre-testing of Instruments of Roll Back Malaria Needs Assessment in the Dangme West District, Ghana. 10 January 1999.

5. Diarra D et al. Roll Back Malaria. Needs Assessment Report. Field Test of Instruments and Methodology in Mali. 2-28 January 1999.

6. Brieger W et al. (1998) Roll Back Malaria. Pre-testing of Needs Assessment Procedures. IDO Local Government, Oyo State, Nigeria. 13 November - 4 December 1998.

7. RBM Country Team. The Final RBM Report on the Pre-testing of the RBM (WHO) Research Instruments, and the Situation Analysis for Action Against Malaria in Petauke District, Zambia. 21 December 1998 - 20 January 1999.

8. Ahorlu CK. (1997) Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control. Tropical Medicine and International Health, 2(5):488-499.

9. Tai,Y.T., But, P. P. H. & Tomlinson, B.(1993) Adverse effects from traditional Chinese medicine: A critical reappraisal. J Hong Kong Med Assoc Vol. 45( 3):197-201

10. Xue,C.C.L., Zhang,A.L., Lin, V., Costa, C. & Story, D.F. (2007) Complementary and Alternative Medicine Use in Australia: A National Population-Based Survey. The Journal of Alternative and Complementary Medicine. 13(6): 643-650.

11. Eisenberg DM et al. (1998)Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. Journal of the American Medical Association, 280(18): 1569-75.

12. Jonas WB.(1998) Alternative medicine - learning from the past, examining the present, advancing to the future. Journal of the American Medical Association, 280(18):1616-1618.

13. United Nations Conference on Trade and Development. Systems and National Experiences for Protecting Traditional Knowledge, Innovations and Practices. Background Note by the UNCTAD Secretariat. Geneva, UNCTD, 2000 (document reference TD/B/COM.1/EM.13/2).

14. Data from Information Resources, Inc. Scanner Data, quoted in Herbal Gram (1998) Journal of American Botanical Council and the Herb Research Association, 43:61.

15. Sofowora, A. (1982) Medicinal Plants and Traditional Plants in Africa. New York: John Wiley.

16. Zhang, X. (2000) Traditional Medicine and Its Knowledge. UNCTAD Expert Meeting on “Systems and National Experiences for Protecting Traditional Knowledge, Innovations and Practices”. Geneva.

17. Agarwal, A. & Narain, S. (1996). Pirates in the garden of India. New Scientist, 152 (2053), 14-15.

18. Government of India  (2000). Protection of biodiversity and traditional knowledge-the Indian experience. Document no. WT/CTE/W/156.

19. Wiser, G.M. & Downes, D.R. (1999). Comments on improving identification of prior art: Recommendations on traditional knowledge relating to biological diversity submitted to the United States patent and trademark office. Washington, DC: Center for International Environmental Law.

20. Timmermans, K. (2003) Intellectual property rights and traditional medicine: policy dilemmas at the interface. Social Science and Medicine. 57, 745-756          

Alessandro Demaio writes about evidence based medicine versus local wisdom and knowledge.

Evidence Based medicine (EBM) has rapidly become a cornerstone of modern healthcare practice and is seen not only to be the answer to delivering safer, more effective and sustainable medicine but to also please health-economists and governments. Health provision everywhere must now be proven before it will be funded or concreted in policy. Administrators and senior clinicians alike are placing the emphasis on the outcomes from large, complex and commonly drug-driven trials rather than experience, time-tested knowledge and sometimes even common sense.

Simultaneously, the divide in healthcare and population-health between the developed and developing worlds continues to widen. But what about medicine based on human intelligence, local knowledge and generations of “evidence”? When it comes to public health, what role does traditional or indigenous knowledge play? In modern medicine with the growing global burden of disease, are we overlooking an important knowledge resource simply because it is not backed by studies?

In 2006, the World Health Organisation and UNAIDS announced their acknowledgement and support that circumcision had a role in HIV/AIDS prevention. This simple and cheap traditional practice had been recognised by local African communities for many years yet was largely ignored by the scientific and medical communities. Instead, expensive drugs and complex treatments were employed as a reactive measure to address this massive problem whilst cheap and effective interventions were delayed. Clinical trials would not have been impossible to perform and yet, at least in part, this did not quickly occur because it is difficult to patent a circumcision! Despite many drugs entering the market throughout this period with expensive trials to back their use, circumcision remained an untapped intervention, absent from the anti-HIV armament.

This reveals a major weakness of evidence-reliance; clinicians will only perform medicine with an evidence-base, evidence usually equals expensive trials and it takes the financial-backing and promise of monetary returns to bring about these trials. So almost by definition, this current system acts as a disincentive for the global medical community to develop and implement the affordable, simple and universally applicable disease treatments we currently need for diseases such as HIV and TB in the third world.

Another issue with the concept of evidence-based medicine is that it is universally applied and regarded as unmalleable. It is rigid and discourages a clinician from using their own judgement and adapting their healthcare provision for the specific environment. A real life example is from a medical student in remote Australia where the geographical isolation as well as sociocultural needs in this population means that medicine has to be ‘culturally-based’. Supporting an individual who chooses to use traditional healing techniques and “bush” medicines whilst refusing to take western pharmacotherapy goes against the evidence but may be appropriate or even better practice. It is far safer for the patient if the clinician is flexible and accommodating, and understanding and appreciative of the cultural context in which the patient presented. This style of medicine may take more time, thought or consideration, but has better outcomes for the patient and the healthcare system alike.

But one must be fair, maverick medicine is not the answer either and, being purely pragmatic, governing bodies and health administrators need to know an intervention will work before they will be willing to fund it. With limited budgets available, it makes sense to support the strategies that have been proven to work through trials and are supported by clinicians and scientists.

Some would argue that is it not simply a matter of one or the other and that age-old wisdom can be a powerful vector for western health modalities. In a recent interview Funke Bugonjoko, Public Health Officer with the WHO, explained that “we as scientists need to learn, we have the [health] message but need to learn how to reach the people appropriately. Medicines are not the answer, telling is not the answer, trust based on mutual respect and understanding is the answer. Health promoters must appreciate the crucial and profound influence of local knowledge and community gatekeepers on community health. Until you understand and penetrate cultural beliefs you cannot affect health-seeking behaviours.”

Evidence based medicine places a strong emphasis on the strength of evidence and particularly the use of randomised controlled trials in proving therapeutic value. Yet a traditional practice that has been used and refined over many generations may be totally ignored by the medical profession. These trials work well when the intervention is clear and the outcome quantifiable, such as with medications. Though when the intervention is a socio-cultural approach with outcomes that modern science cannot explain, such as with traditional healers, its inability to be rigorously proven through testing makes it redundant to modern medicine. Furthermore, unless there is monetary gain for pharmaceutical companies or demonstrable cost-effectiveness and tax-savings for government investment, it is very difficult to find the support to conduct the trials even if these are possible.

But it is not all doom and gloom, things are being done to address this conflict between scientific and traditional evidence. In Malawi, Hotz and Gibson report on a laboratory that has been established to analyse traditional foods, cooking, preparing techniques in an effort to provide cheap and effective solutions to the growing problems of malnutrition and starvation amongst local communities. Close-by, the African Medical and Research Foundation have been analysing the use of locally trained health workers and their efficacy in delivering appropriate healthcare and screening programs. In other terms, if clinicians and scientists are unwilling to recognise anything without an evidence-base then these few and financially-able traditionalists will prove their potions!

In conclusion, it is crucially important in modern medical practice to encourage clinicians to provide care with an evidence base. But one must be healthily critical of a system that encourages the provision of health only when endorsed by expensive trials, inevitably funded with profits in mind. Evidence-based medicine, like anything, has its limitations and does not negate the need for careful analysis, thought and human judgement. No one endorses rebel medicine of the style of Gregory House, but at the same time, age-old knowledge, techniques and practical, applicable interventions or treatments should not be automatically discounted due to a lack of scientific evidence.

After all, a trial of 1000 people or 1000 years of ‘trial and error’, which is really the evidence base? Something to ponder…

Alessandro Demaio
Overall Chairperson
Asian Medical Students’ Association

sandro.demaio@gmail.com

African Medical and Research Foundation, Kenya Office. (2007) Community Commitment Builds Community Health.

Hotz C and Gibson R. (2007) Traditional Food-Processing and Preparation Practices to Enhance Bioavailability of Micronutrients in Plant-Based Diets.

The Journal of Nutrition. 137, 1097-1100.World Health Organization and United Nations. (13 December, 2006) Press Statement on Kenyan and Ugandan Trial Findings Regarding Male Circumcision and HIV.  

Kush Patel reports on the violence that occurred in Kenya following the elections earlier this year.

For many years, Kenya has been considered as a refuge for people fleeing their own country because of domestic turmoil. However, on 29th December 2007, shouts emanated from an angry throng that had gathered on the streets. Marching determinedly towards them was a battalion of riot police. Within seconds, the rioters hurled stones at the police, who counterattacked using bullets and tear gas. In other parts of the country, youths clutching machetes and sticks launched themselves upon opposing tribes. Events such as these set the scene for a blood bath that has resulted in thousands of people injured, dead or homeless. Several camps for internally displaced people (IDP) were set up all over the country. Governmental and non-governmental organisations (NGOs) such as Merlin, Medecins sans frontiers (MSF), the Red Cross, AMREF and others, deployed teams to provide humanitarian aid.

Post-election violence in Kenya results in displacement

photo source: savethechildren.org/au

Trauma victims requiring medical attention overwhelmed the medical facilities. When particularly violent clashes broke out, trucks full of injured or dead people arrived at hospitals, which in-turn became so over-crowded that patients were being treated on the corridors. A system of triage was implemented at many institutions, thus helping to treat the most severe patients first. (2,3) Patients were being rushed in with broken bones, stab injuries, blunt trauma and burns. Doctors reported certain cases where patients had sustained machete wounds that resulted in near-amputations. (3) Flying surgical teams were put on high alert, responding to violence in inaccessible regions. (4) In the worst hit areas, temporary first-aid posts were setup that quickly stabilized victims, while waiting for transport to hospitals. Any person who was critical and needed specialist care was air-lifted to the closest hospital. (3) Many of the victims were (and some still are) mentally traumatized from witnessing the violence or having lost loved ones. These people were given psychosocial support by medical personnel. (2,3)

Cases of sexual violence increased dramatically. These incidents took place both within IDP camps and outside. This will probably result in increased incidence rates of sexually-transmitted diseases, including HIV infection. Counselling and screening for sexually-transmitted infections have commenced in certain areas. (4)

Many people have been displaced and gathered at temporary IDP camps. At these camps severe public health consequences can manifest amongst the IDPs.. Four main reasons behind this are that the population is displaced, food becomes scarce, health care diminishes and living conditions worsen. Studies have shown that mortality rates are usually highest immediately after the migration. (1) Apart from the acute emergencies, an increasingly large number of IDPs need to be accommodated. At each IDP camp, tents were pitched, food and water was provided, sanitation and lavatory facilities were set up and medical camps were established. (2-6) Other essential equipment such as bed nets, (6) cooking apparatus, (3) and clothing, (2,4) was provided to the IDPs. Most IDPs had left their homes without anything. For many, important documentation was lost. Therefore, the task of registering the IDPs and getting new identification cards for them was set into motion. In order to keep the IDPs busy and lessen their emotional stress, some were given responsibilities in the camps such as cleaning. (2) Some NGOs have setup tracing agencies that help reunite lost family members.(4) Planes and helicopters had to be employed to deliver medical and other essential supplies to ill-equipped areas.(3)

The most prevalent diseases amongst IDPs are diarrheal diseases, measles, acute respiratory infections, and malaria. Additionally, many people became malnourished because of the lack of food. This aggravates diseased states and worsens the patient’s prognosis.(1) At a single camp, 541 consultations were done mainly for respiratory tract infections.(3) Most of these patients were children and many had a poor prognosis. Factors that contribute to a high prevalence of respiratory tract infections are: over-crowding, poor ventilation, inadequate shelter, and prolonged exposure.(1)
The measles immunization was provided for children.(3) For those who survive the initial illness, it can lead to malnutrition and vitamin A deficiency. Previously, measles has accounted for high mortality rates amongst children in refugee camps. However, it is less of a threat now compared to before 1990.(1)

Diarrhoeal diseases are a common phenomenon in IDP camps. Factors that contribute to their high prevalence are unsanitary conditions and unsafe drinking water. Cholera and dysentery are the main problems. In some IDP camps, diarrhoeal epidemics had broken out. These were usually treated with oral rehydration salts. However, any serious cases of diarrhoea were referred to a hospital.(4)

Kenya has a high prevalence of tuberculosis (TB) (7) and AIDS. (8) A lot of IDPs with TB or AIDS fled their homes without anything, including their anti-tuberculosis or antiretroviral drugs.(2,3,6) Adding to this, the number of patients attending HIV/AIDS clinics reduced dramatically.(3) This can have serious consequences on their health, as non-compliance results in the development of drug-resistance. Patients also become susceptible to opportunistic infections and their risk of morbidity and mortality increases.(8) One report mentioned a woman trapped at home, unable to gain access to a new dose of anti-retrovirals. As a result, when she was found by relief workers, an infection had set in and she had to be admitted to hospital.(9) Another hurdle with respect to anti-retrovirals is that many HIV patients were not getting adequate nutrition. This resulted in patients unable to tolerate their medication, further increasing non-compliance.(9) Patients with tuberculosis, face a similar scenario where drug-resistance develops.(4,7) The problem with this is that patients then require second-line drugs that are more expensive than first-line drugs.(4) Long-term effects of this may result in increased infection rates within the population. These 2 diseases were a major concern for the NGOs, who constantly held testing clinics, offered counselling and provided medication.(6,2,3) Thankfully this volatile situation has calmed down allowing people to piece together their lives. Medical attention has also improved in most areas. (6)

A correspondent from Merlin gave the following account of a typical day at an IDP camp:
The day usually starts off early, with a meeting discussing the day’s agenda. A clinic is setup wherever space is available (a vacant room or under a tree). Patients are then prioritized according to their level of urgency. Immunizations, HIV testing and counselling and treatment for minor illnesses are provided to those who need them. For those who require referrals to health centres or hospitals, transportation is arranged. Other team members conduct health education sessions for patients while they wait for their consultation.

Kush Patel
Imperial College London
kush.p.patel04@imperial.ac.uk

References
(1) Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu.Rev.Public Health 1997;18:283-312.
(2) Kenya Red Cross operations update. http://www.kenyaredcross.org/highlights.php?newsid=61&subcat=1, 2008.
(3) Medecins sans frontiers. http://www.doctorswithoutborders.org/news/report.cfm?id=2470, 2008.
(4) International committee of the Red Cross. http://www.irinnews.org/Africa-Country.aspx?Country=KE, 2008.
(5) AMREF Kenya news and press releases. http://kenya.amref.org/index.asp?PageID=10, 2008.
(6) Merlin newsletters. http://www.merlin.org.uk/Where-we-work/Kenya.aspx, 2008.
(7) O’Boyle SJ, Power JJ, Ibrahim MY, Watson JP. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). Int.J.Tuberc.Lung Dis. 2002 Apr;6(4):307-312.
(8) Frick PA, Gal P, Lane TW, Sewell PC. Antiretroviral medication compliance in patients with AIDS. AIDS Patient Care STDS 1998 Jun;12(6):463-470.
(9) BBC news on Kenya. http://news.bbc.co.uk/1/hi/in_depth/africa/2008/kenya/default.stm, 2008.

Sandeep Kishore is one of the winners of The Lancet-GHEC 2008 prize for his work in petitioning the WHO to include simvastatin (Zocor), a statin drug used for heart disease, on the Essential Medicines List (EML). The WHO approved the petition in 2007, adding the drug to the EML. A summary of Sandeep’s work is below.

Heart disease has now become the leading cause of death globally, with nearly 80% of worldwide deaths occurring in the developing world. Long considered a disease of affluent countries, heart disease presently claims twice as many lives as HIV/AIDS, tuberculosis and malaria in low-income countries. Higher rates of urbanization and tobacco use help explain this trend. However, while there has been much effort to enhance access of basic, essential medicines for infectious diseases, there has been comparatively little attention paid to curbing heart disease and related chronic diseases in the developing world.

To address this problem, our student group at Weill Cornell initiated a campaign to identify schemes to enhance access to life-saving medicines for heart disease. We petitioned the World Health Organization (WHO) that a statin drug be included on the Essential Medicines List (EML) or Model List. This list was established to provide guidelines for developing countries for selecting high priority drugs, which should be supplied to their citizens inexpensively. We chose simvastatin (Zocor), originally manufactured by Merck, based on its worldwide availability, cost-effectiveness and the interest of generic firms in producing it. According to the International Drug Price Indicator Guide and our consultations with global pharmaceutical firms, generic versions of the medicine presently cost $40/year –10 cents/day - down from the nearly $1,200/year a couple of years ago. Efficacy data consistently show that statins reduce low-density lipoprotein cholesterol (LDL) levels by 25-30% in individuals at high risk for heart disease. Critically, our research indicated statins were effective in different ethnic populations globally. Through collaboration with the Clinton Foundation, we felt confident that a high quality, reliable supply of statin drugs could be made available to developing countries.

In April 2007, the WHO approved our petition, adding simvastatin to the EML. This qualification now enables mass drug donations of the heart drug by all United Nations’ organizations to 156 national pharmaceutical inventories. Furthermore, national governments that work with the WHO are encouraged to recognize heart disease as a serious health concern. The EML has a proven track record of enhancing access to essential medicines. It is too early to know whether access to statins in poor countries has increased. We recognize that efforts to increase statin use in the developing world must be taken in parallel with similar cost-effective interventions, such as, national diet and exercise programs and campaigns to reduce global tobacco consumption. However, increased statin availability is a first step. We note that that this work was student-led, researched with assistance of medical librarians and supported by the Dean of our medical college. Its success indicates that activist university students and faculty can be primary players in making significant changes to global public health policy.

The application is publicly accessible via the WHO here: http://mednet3.who.int/EML/expcom/expcom15/applications/newmed/statins/Statins.pdf

Adam Briggs, final year medical student, University of Oxford.

Human resources for health are in crisis. The migration, or brain drain, of healthcare professionals from developing to developed countries is legitimised by the World Trade Organisation’s General Agreement in Trade Services and fuelled by significant push and pull factors. Push factors such as inadequate salaries, poor working conditions, and conflict all affect an employee’s decision when promised better training, higher socio-economic status, and political stability in another country.¹ Internal migration of doctors and nurses to urban areas and the private sector also has devastating effects on many poor and rural populations. Box 1 helps to put the current situation into context.

• Africa carries 25% of the world’s disease burden yet has only 3% of the world’s health workers and 1% of the world’s economic resources.²
• Between 1998 and 2002, Ghana lost roughly £35 million of its training investment in health professionals and the UK saved £65 million by recruiting them.³
• About 20% of African-born physicians are working overseas in developed countries.⁴
• Conflict only exacerbates problems with human resources for health: in Liberia, 14 years of war have reduced the numbers of practicing doctors from 237 to less than 20.⁵

Box 1. Some of the problems in human resources for health

March 2008, saw the first Global Forum on Human Resources convened by the Global Health Workforce Alliance (GHWA) in Kampala, Uganda. The Global Forum launched the Agenda for Global Action: a plan to address human resources for health problems over the coming decade, set targets, and monitor progress and accountability. GHWA was formed in May 2006, and through many programmes and publications, such as the Human Resources for Health Action Framework, it is helping countries with their health-workforce problems.^6-8

The UK based charity, Merlin (medical relief, lasting health care), ‘responds worldwide with vital health care and medical relief for vulnerable people caught up in natural disasters, conflict, disease and health system collapse.’⁹ It is an example of a non-governmental organisation (NGO) that can help to fulfil GHWA’s Agenda for Global Action. Established in 1993, Merlin has organised missions to countries as diverse as Afghanistan, Rwanda, and Honduras. Merlin’s experience in helping restructure a health workforce in countries with significant endemic problems, known as fragile states, has shown that an appropriate living wage, workforce restructuring measures, and a meritocratic promotion system are crucial issues. Their Director of Health and Policy, Linda Doull, wrote a comment in Lancet about human resources for health in fragile states.¹⁰ In the article she stressed the need for a strategic approach to tackle human resources for health crises which encompass both short-term and long-term solutions. I spoke with her to find out more about Merlin and how they’re working to reduce inequality of human resources for health in such difficult environments.

Merlin’s mandate is to work in areas requiring acute relief, and to work with the country through to recovery; they recognise that solving health problems is a long-term issue. Merlin does this through working at the level of both the community and the government to rebuild the health system.

I asked Linda what her view was on the GHWA and whether it will be effective in solving the human resources for health crisis. She believes that putting human resources for health at the top of the global health agenda is a very positive step, which will hopefully act as a catalyst for coordinated action. She compared the GHWA to the millennium development goals - often touted as unachievable but acting as a focus for political initiative.

Linda explained that there are several stakeholders that need to act to solve the human resources crisis. Ultimately, it can be argued that the responsibility rests with the government; however, does that government have sufficient investment? Governments in fragile states are often unwilling or unable to provide basic services. “Take Liberia as an example: Merlin’s budget (in Liberia) is as big as the health budget for the ministry in Liberia. Why are those distortions there? Maybe international donors aren’t willing to invest. Maybe the ministry has money, but has chosen to invest elsewhere.” She argued that perhaps NGO funding needs to be done differently. For example, perhaps Merlin needs to engage more at a national level offering technical assistance to develop curricula. “There is no one single factor, there is a mix. (We must) recognise that that (mix) has to come together and has to come together earlier. Hopefully that’s what the global alliance will help to facilitate.”

It has been suggested that the recruitment policy of some NGOs perpetuates the drain of health care professionals away from areas of need in their local health service. Merlin protects against this by advertising vacancies and vetting those who apply rather than actively recruiting staff. If, for example, a senior health minister applied for a post then they would only consider offering the job if the ministry agreed to release the minister, rather than give that person the opportunity to leave crucial local employment. Merlin prefers to work within the existing health system, with the local health care professionals. Where there are gaps in the clinics Merlin works with the relevant country’s health ministry to identify and transfer a staff member to that hospital rather than recruit staff members themselves. However, limited resources mean that staff transfer is often not easy and staff may not want to move. As an interim solution, Merlin will often employ an international health worker.

So what can we, as students, do to help? Organisations such as Merlin need volunteers who are highly skilled at both a technical level and a managerial level; senior registrars and consultants are ideal. However, as students we can still have a role. We need to recognise global health needs and be advocates through organisations such as Medsin in order to keep the issue of human resources for health on the global political agenda. As Linda says “(Medical professionals in the developed world) are very, very lucky and every health worker should be allowed to have a level of investment that makes them a competent safe practitioner, so if nothing else remember that.”

Solving human resources for health problems is a difficult balancing act. NGOs want to employ local health care workers, but do not want to relocate them from areas of health need; overseas doctors rarely provide a permanent solution. Although acute care is essential in many situations, for lasting solutions I believe that change needs to take place at an administrative level and until this happens, the problems highlighted in box 1 will continue. Local doctors should not be blamed for wanting to leave war-torn and impoverished countries but as a medical community, from students to consultants, we should be pressurising governments through NGOs and our nominated unions for better working conditions for our international colleagues.

References

1. World Health Organisation. World health report 2006: working together for health. Geneva: World Health Organisation; 2006.
2. Robinson M, Clark P. Forging solutions to health worker migration. Lancet 2008;371:691-93
3. Martineau T, Decker K, Bundred P. “Brain drain” of health professionals: from rhetoric to responsible action. Health policy 2004;70:1-10
4. Clemens MA, Pettersson G. New data on African health professionals abroad. Human Resources for Health 2008;6:1
5. Interagency Health Evaluation, Liberia, 2005: final report. http://www.unhcr.org/research/RESEARCH/456ac0682.pdf (last accessed 12/03/08)
6. The Global Health Workforce Alliance. Strategic plan. 2006. http://www.who.int/workforcealliance/GHWA_STRATEGIC%20PLAN_ENGLISH_WEB.pdf (last accessed 12/03/08)
7. The Global Health Workforce Alliance. Working groups and task forces. http://www.who.int/workforcealliance/workingroups/en/index.html (last accessed 12/03/08)
8. HRH Action Framework. http://www.capacityproject.org/framework/ (last accessed 12/03/08)
9. Merlin. Medical relief, lasting health care. http://www.merlin.org.uk/ (last accessed 12/03/08)
10. Doull L, Campbell F. Human resources for health in fragile states. Lancet. 2008;371:626-27.