The Lancet Student

On the Web

The Lancet Student Recommends

  • Be a part of a groundbreaking discussion on global health action for the next decade with prominent leaders. Visit www.UCSFGlobalHealthSummit.org for more information.



Random | Archive | Click image to see detail

Most Recent Articles

This Week in The Lancet

  • Volume 376
  • September 3, 2010

Access to Healthcare

Fractured

Monday, August 16th, 2010

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

Strengthening our natural defences: a new drug candidate and a new approach to fighting infectious diseases

Thursday, September 2nd, 2010

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.

Pic1

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 3rd 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.

P-Mapa purified: a medicine in the pipeline (Credit: Courtesy Farmabrasilis)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]

Misinformation as a barrier to family-planning use

Monday, July 19th, 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

Introducing the Cuban Healthcare Model into the Favelas of Niterói, a municipality of Rio de Janeiro

Thursday, July 8th, 2010

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.

Rio1Fig 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.

Rio2Fig 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.

Rio3Fig 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

Health for all: where does Canada stand?

Monday, July 5th, 2010

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.

article MonTable 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

Philosophy of Medicine in the Third Reich

Thursday, July 1st, 2010

Krakow1

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

Krakow2

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

Improving communication at the end of life

Monday, June 28th, 2010

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

Current worldwide trends of folic acid supplementation and neural tube defects

Thursday, June 24th, 2010

spina bifida

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.

(more…)

Poverty – A Global Humanitarian Crisis

Thursday, June 3rd, 2010

fig1

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.

g1 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

Problems in Cambodia following the Khmer Rouge Regime

Thursday, April 29th, 2010

fig1 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.

fig2 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].

killing tree 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].

fig1 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

fig4 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:

1. Kiljunen K. Power politics and the tragedy of Kampuchea during the seventies. Bull Concerned Asian Scholars. 1985: 1749-1764.
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.
6. Glass RI, Cates W Jr, Neiburg P, et al. Rapid assessment of health status and preventative- medicine needs of the newly arrived Kampuchean refugees, Sa Kaeo, Thailand. Lancet. 1990; 1: 868-872.
7. United Nations Security Council. Report of the Secretary General on Cambodia. New York, NY: United Nations Security Council; February 19, 1992.
8. Stockwell A, Whiteford H, Townsend C, Stewart D. Mental health policy development: case study of Cambodia. Australasian Psychiatry. 2005; 13: 190-194.
9. Mental Health Subcommittee Working Group. Draft Cambodian National Mental Health Plan 2003-2022. Phnom Penh: Ministry of Health, 2002.
10. Mollica R, Wyshak D, de Marneffe D, et al. Indochinese versions of Hopkins Symptoms Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987; 144: 497-500.
11. Mollica R, Wyshak D, Lavelle J. The psychosocial impact of war, trauma and torture on Southeast Asian refugees. Am J Psychiatry. 1987; 144: 1567-1572.
12. Mollica R, Caspi-Yavin Y, Bollini P, et al. The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992; 180: 111-116.
13. Hu T. Financing global mental health services and the role of WHO. The Journal of Mental Health Policy and Economics. 2003; 6: 145-147.
14. Fawthrop T, Jarvis H. Getting away with Genocide? Cambodia’s long struggle against the Khmer Rouge. London, England: Pluto Press; 2004.
15. Extraordinary Chambers in the Courts of Cambodia. Phnom Penh, Cambodia: ECCC. [Accessed on: February 12, 2010]. Available from: http://www.eccc.gov.kh/.
16. Sonis J, Gibson J, Jong J, et al. Probable posttraumatic stress disorder and disability in Cambodia: associations with perceived justice desire for revenge and attitudes towards the Khmer Rouge trials. JAMA. 2009; 302(5): 527-536.
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.
18. Orth U, Maercker A. Do trial perpetrators retraumatize crime victims? J Interpers Violence. 2004; 19(2): 212-227.

play free slots machines no downloads; Free Sign Up Bouns Slots igt slots online; play free slots for fun only Virtual Games Online For Free free slots bonus codes igt games download Play Free Slots No Sign Up minimum deposit $10 casino casino free came Free Online Casino download slot machines poker no deposite casino codes Casino Bonus No Deposit Required play for fun and free instant casino slots usa casinos no deposits Online Casino No Downloads Or Sign Ups slots gratis googlefreeslots, Free Online Casino Slots party city free no download slot play for fun Absolutely No Deposits no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play Free Casino Machines ffree online slot games no downloads play free slots for fun only New Player No Deposit Bonus Casino free slots bonus codes igt games download Printable Free Las Vegas Coupons minimum deposit $10 casino casino free came No Deposit Rtg Casino Bonus Codes download slot machines poker "aladin online casino" Indian Dreaming Slot Machine play for fun and free instant casino slots usa casinos no deposits

The Newest No Deposit Casinos

slots gratis real casino slot machines, Slot Of Vegas Bonus Code party city free no download slot play for fun Vegas Casino Online Coupon Codes no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free No Deposit Casinos Usa Friendly ffree online slot games no downloads play free slots for fun only

No Deposit Slots

free slots bonus codes free casinos on line hour play Free Slots And Card Games minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Online 10 Casino Deposits download slot machines poker no deposite casino codes Free Slots With Bonus Games play for fun and free instant casino slots usa casinos no deposits New Flash Casino slots gratis googlefreeslots, No Deposit Casino Online party city free no download slot play for fun Legal Online Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. On Line Casinos For United States ffree online slot games no downloads free rtg casino codes Casino With No Deposit First Play Bonus free slots bonus codes igt games download Slot Machines For Fun Not Money minimum deposit $10 casino casino free came Us Players Casinos download slot machines poker "aladin online casino" Casino Download Igt play for fun and free instant casino slots usa casinos no deposits Free Slots Bonus Codes slots gratis googlefreeslots, Flash Casinos No Deposit In Uk party city free no download slot play for fun
Play Monopoly Free Online no deposit coupon codes instant play free fun slots no download slots machine Online Vegas Casino No Deposit Bonus ffree online slot games no downloads play free slots for fun only Slot Machine Games free slots bonus codes igt games download Wild Vegas No Deposit Coupon Code minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free Slot Machine Online download slot machines poker no deposite casino codes No Download No Deposit Casino play for fun and free instant casino slots usa casinos no deposits

Slot Machines Gratis

slots gratis real casino slot machines, Las Vegas Free Online Slot Machines party city free no download slot play for fun Play Casino Monopoly Free no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free All Slots Casino ffree online slot games no downloads

play free slots for fun only

All Slot Flash Casino

free slots bonus codes no deposit casino free bonus codes! Top 5 Best Playmoney Casino minimum deposit $10 casino casino free came Free Online Strip Games download slot machines poker no deposite casino codes Slot Machines Free Sites play for fun and free instant casino slots usa casinos no deposits Search One Hour Free Play Casinos With No Deposites slots gratis googlefreeslots, Casino No Deposit Sign Up Bonus Codes party city free no download slot play for fun Online No Deposit Casinos no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Munsters Slot Machine ffree online slot games no downloads play free slots for fun only Newest Rtg No Deposit Bonus Codes free slots bonus codes igt games download Best No Depoit Casino Bonuses minimum deposit $10 casino casino free came Online Casino No Deposit Free Money download slot machines poker no deposite casino codes Us Free Slot Tournaments play for fun and free instant casino slots usa casinos no deposits Free Play No Deposit Casinos slots gratis googlefreeslots, Free Play Casnisos party city free no download slot play for fun Play Free Bonus Slots no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Wildvegas Coupon Code ffree online slot games no downloads

play free slots for fun only

Free Online Craps No Download free slots bonus codes free casinos on line hour play Best Casino minimum deposit $10 casino casino free came Slots Nuts download slot machines poker no deposite casino codes Sun And Moon Casino Slot Game play for fun and free instant casino slots free play time at casinos! Club Player Casino Codes slots gratis googlefreeslots, Casinos For Usa Players That Have No Deposit Free Money party city free no download slot play for fun Free Slots Machines To Play For Fun no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play For Fun Casino Slots ffree online slot games no downloads play free slots for fun only Google Free Slot Machines free slots bonus codes igt games download Best Free Slot Tournaments Online minimum deposit $10 casino casino free came Video Slot Machines With Bonus For Sale download slot machines poker no deposite casino codes Free Casino Spins play for fun and free instant casino slots usa casinos no deposits Online Casinos Free Play In South Africa slots gratis googlefreeslots, Play Free Slots Cleopatra party city free no download slot play for fun Minimum Deposit 10 Dollars Poker no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Roulette No Download ffree online slot games no downloads play free slots for fun only Casinos That Has Monopoly Slots To Play For Free free slots bonus codes igt games download Free Google Game minimum deposit $10 casino casino free came Casino Games Html Code download slot machines poker no deposite casino codes Online Casino With Little Green Men Slot play for fun and free instant casino slots

usa casinos no deposits

Poker Machines Strip slots gratis real casino slot machines, New No Deposit Casino Bonus Codes party city free no download slot play for fun Instant Play Free Fun Slots No Download Slots Machine no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Casino Coupons ffree online slot games no downloads play free slots for fun only Free Bonus Sign Up free slots bonus codes igt games download Online Gambling No Deposit minimum deposit $10 casino casino free came Slots Of Vegas Casino Coupon Codes download slot machines poker no deposite casino codes No Deposit Us Friendly play for fun and free instant casino slots usa casinos no deposits Newcasinobonus slots gratis googlefreeslots, Free Bonuse Casino On Line party city free no download slot play for fun Free Slot Play No Download Or Sign In no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Bonus Monster ffree online slot games no downloads free rtg casino codes Free Slotmachine Coupons free slots bonus codes igt games download Us Palyers Casino No Deposit minimum deposit $10 casino casino free came Play Free Casino Slot Games No Download download slot machines poker no deposite casino codes No Deposit Casino Us Ok play for fun and free instant casino slots

usa casinos no deposits

Casino No Deposit Sign On Bonus slots gratis real casino slot machines, Rtg Codes party city free no download slot play for fun Online Cassino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Blackjack On Line Com No Down Load ffree online slot games no downloads play free slots for fun only Win Cash Online Casino free slots bonus codes igt games download Slots Plus minimum deposit $10 casino casino free came Casino Slot Nuts download slot machines poker no deposite casino codes New Casinos For Us Players play for fun and free instant casino slots usa casinos no deposits Make Money Online Free No Deposit slots gratis googlefreeslots, Brand New Casinos Us Players party city free no download slot play for fun Casino Spin Games
no deposit coupon codes instant play free fun slots no download slots machine Free Online Casino Promotions ffree online slot games no downloads play free slots for fun only Free No Deposit Casino Chips For Club Player Casino free slots bonus codes igt games download Sports Book Com Bonus Code minimum deposit $10 casino casino free came Cherry Slots Free No Download download slot machines poker no deposite casino codes Free Keno Slot Games play for fun and free instant casino slots usa casinos no deposits Online Blackjack No Minimum Deposit slots gratis googlefreeslots, Wildvegas Coupons And Codes party city free no download slot play for fun Wild Vegas No Deposit Bonus Codes no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Gambling Federation Casinos No Deposit ffree online slot games no downloads play free slots for fun only Free Vegasslots free slots bonus codes igt games download Golden Casino Bonus Codes minimum deposit $10 casino casino free came No Deposit Casino Coupon Codes download slot machines poker no deposite casino codes Online Free Casinos No Downloads play for fun and free instant casino slots usa casinos no deposits Online Flash Slots slots gratis googlefreeslots, No Deposit Required Online Casino party city
free no download slot play for fun 10 Dollar Casinos no deposit coupon codes instant play free fun slots no download slots machine Free Slots Machines Only For Fun ffree online slot games no downloads play free slots for fun only No Deposit Casinos Free Money Codes free slots bonus codes igt games download Slot Game Free minimum deposit $10 casino casino free came Free Casino Chip Codes download slot machines poker no deposite casino codes Free Usa Casino Games play for fun and free instant casino slots

usa casinos no deposits

Online Gambling Using Your Paypal Account slots gratis real casino slot machines, 1 Hour Free Play Casinos Accepting Us Players party city free no download slot play for fun
Play Online For Free Casino Slots no deposit coupon codes instant play free fun slots no download slots machine Slot Machines Milk Money ffree online slot games no downloads play free slots for fun only Club World Casino Codes free slots bonus codes igt games download Free Stampede Slot Machines minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. No Deposit Rtg Casino Bonuses download slot machines poker no deposite casino codes Free Slots Games Nodownload.com play for fun and free instant casino slots usa casinos no deposits Free Fun Casino Slots No Download No Registration slots gratis googlefreeslots, Cirrus Casino Coupon Code No Deposit party city free no download slot play for fun Holey Card Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free No Bonus Casino Usa Players ffree online slot games no downloads play free slots for fun only

Forum Redeem Coupon Cirrus Casino

free slots bonus codes

play free diamond slots New Codes For Online Casinos minimum deposit $10 casino casino free came Free Bonus Slot Games download slot machines poker no deposite casino codes Slot Games You Dont Have To Download play for fun and free instant casino slots usa casinos no deposits Online Games slots gratis googlefreeslots, Top Dollar Machine Free Slots party city free no download slot play for fun No Deposit Casinos For American Players no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Golden Casinofree Online ffree online slot games no downloads play free slots for fun only Free Play Casinos For Real Money free slots bonus codes igt games download Online Free No Download Games minimum deposit $10 casino casino free came Free Slot Machine Online No Download download slot machines poker no deposite casino codes Las Vegas Casino Slots Games Free play for fun and free instant casino slots usa casinos no deposits Free Play Slot slots gratis googlefreeslots, Free Play Fun Poker 2010 party city free no download slot play for fun Usa Casinos Offering Minimum Deposits Of 10 no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Lucki 18 Casino Bonus No Deposit ffree online slot games no downloads play free slots for fun only Googlefreeslots free slots bonus codes igt games download Cleopatra Game Free minimum deposit $10 casino casino free came Instant Play Slots download slot machines poker "aladin online casino" Las Vegas Printable Coupons play for fun and free instant casino slots usa casinos no deposits Casino Slot Machine Games slots gratis googlefreeslots, Slots Plus No Deposit Codes party city free no download slot play for fun Cirrus Casino Free Codes no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Usa Casino Tournaments ffree online slot games no downloads free rtg casino codes Best Play For Fun Casinos free slots bonus codes igt games download No Deposit Free Money Slot Tournaments minimum deposit $10 casino casino free came Free Slot Machines download slot machines poker no deposite casino codes Slots For Fun Only Down Load To Play play for fun and free instant casino slots usa casinos no deposits Free Money Casino No Deposit slots gratis googlefreeslots, Free Las Vegas Clipart party city free diamond slot machine games No Deposit Required Casino Bonus Forum no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Used Casino Machine ffree online slot games no downloads play free slots for fun only Flash Slots free slots bonus codes igt games download Best Nd Casino Bonus minimum deposit $10 casino casino free came Guide To Online Casinos download slot machines poker no deposite casino codes Free Casiino Slots To Play For Fun play for fun and free instant casino slots

usa casinos no deposits

Coupons No Deposits slots gratis real casino slot machines, Texas Tea Slots For Free party city free no download slot play for fun Bonus Slots Free
no deposit coupon codes instant play free fun slots no download slots machine Play Free Video Slot Machines ffree online slot games no downloads play free slots for fun only Frog Prince Free Slot Ply free slots bonus codes igt games download Casino Avec Coupon Code minimum deposit $10 casino casino free came No Deposit Casino Bonus download slot machines poker no deposite casino codes New Instant Free Casino Slots Games play for fun and free instant casino slots free play time at casinos! Sa No Deposit Bonus Online Casinos slots gratis googlefreeslots, Windows Casino Free Bonus Code party city free diamond slot machine games Casino No Deposit Sing Up Bonus no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casinos Gratis Slot ffree online slot games no downloads play free slots for fun only Casino 888

free slots bonus codes

free casinos on line hour play Free Casino Chips And Codes minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. No Deposit Free Spins download slot machines poker no deposite casino codes Free Play Casinos Codes play for fun and free instant casino slots free play time at casinos! Freeslots Casino Slots slots gratis googlefreeslots, Munsters Free Slots party city
free no download slot play for fun Free Money No Deposit Casino That Takes All Us Players no deposit coupon codes instant play free fun slots no download slots machine Vegas Casino For Fun Games ffree online slot games no downloads play free slots for fun only Search Free Slots Cool free slots bonus codes igt games download Java Game For Real Money In India minimum deposit $10 casino casino free came Monopoly Slots Usa download slot machines poker no deposite casino codes Newest Free Usa Online Slots play for fun and free instant casino slots usa casinos no deposits

All Playtech Nodepositcasinos

slots gratis real casino slot machines, Codes For No Deposit Bonus For Las Vegas Usa Casino party city free no download slot play for fun Casino Clip Art no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Casinos For Usa Players ffree online slot games no downloads free no download monopoly game

Cirrus Casino No Deposit Bonus Codes

free slots bonus codes free casinos on line hour play Free Casino No Deposit Money minimum deposit $10 casino casino free came Bonus Monster Casino Codes download slot machines poker no deposite casino codes Free Games No Registration play for fun and free instant casino slots usa casinos no deposits Virtual Casino Bonus Code slots gratis googlefreeslots, All Casinos In Usa With New Codes party city free no download slot play for fun Casino With Free Play Cupons no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Real Vegas Online Fun Only ffree online slot games no downloads play free slots for fun only Online Casino With Free Credits And No Download free slots bonus codes igt games download Online Casino Free Money No Deposit minimum deposit $10 casino casino free came New Free No Deposit Casino Bonus Codes download slot machines poker no deposite casino codes Play Free Vegas Bare Casino Games play for fun and free instant casino slots usa casinos no deposits No Deposit Casino

slots gratis

real casino slot machines, Online Casino With Paypal party city free no download slot play for fun Slots Gratis On Line no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Casino Slots No Download Required Con ffree online slot games no downloads play free slots for fun only Video Slot Machines free slots bonus codes igt games download Las Vegas Usa Casino No Deposit minimum deposit $10 casino casino free came 7 Free Online Slot Machines download slot machines poker no deposite casino codes Play Free Slot Machine Games No Downloads play for fun and free instant casino slots usa casinos no deposits Free Clip Art Slot Machine Picture

slots gratis

real casino slot machines, Free Slotmachinegame With No Download party city free diamond slot machine games Casino Slot Machine Free To Play no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play Online Slots Free Win Real Money ffree online slot games no downloads play free slots for fun only Sun And Moon Casino Slots free slots bonus codes igt games download United States No Deposit Online Casinos minimum deposit $10 casino casino free came Online Casino No Deposit Codes download slot machines poker no deposite casino codes Party City Casino Codes play for fun and free instant casino slots usa casinos no deposits Casinos With The Best Payouts In Las Vegas slots gratis googlefreeslots, Cirrus Casino Codes party city free no download slot play for fun Betroyalcasino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Cirrus Casino No Deposit Code ffree online slot games no downloads free rtg casino codes Free Slots No Downloads Play Free free slots bonus codes igt games download Free Slot Machine Games Online minimum deposit $10 casino casino free came Play Online Cherry Master For Free download slot machines poker no deposite casino codes Freeyahoo Casino Games play for fun and free instant casino slots usa casinos no deposits Real Free Money Casinos slots gratis googlefreeslots, Play Texas Tea For Free party city free no download slot play for fun Free Online Casino No Download no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free New Online Slots ffree online slot games no downloads free rtg casino codes New Microgaming Bonus Codes free slots bonus codes igt games download
Free Slots No Sign Up No Downloads minimum deposit $10 casino no deposit casino coupon codes Online Casino Bonus Codes download slot machines poker "aladin online casino" Monoploy Slots play for fun and free instant casino slots usa casinos no deposits Printable Las Vegas Coupons slots gratis googlefreeslots, Free Casino Slotmachine Games party city free no download slot play for fun Play Monopoly Online For Free No Downloads no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Casion ffree online slot games no downloads free rtg casino codes Nodepositcasinobonus free slots bonus codes igt games download Usa Casino Free Bonuses No Deposit minimum deposit $10 casino casino free came List New Us Online No Deposit Casinos download slot machines poker no deposite casino codes Free Monopoly Download play for fun and free instant casino slots usa casinos no deposits Games Download slots gratis googlefreeslots, Slots Plus No Deposit Code party city free no download slot play for fun
Free Online Gaming no deposit coupon codes instant play free fun slots no download slots machine Free On Line Casino In South Africa ffree online slot games no downloads play free slots for fun only No Cash Bonus Usa

free slots bonus codes

free casinos on line hour play Us 1 Hour Free Casino minimum deposit $10 casino casino free came Play Practice Casino download slot machines poker no deposite casino codes No Deposit Freespins Casino play for fun and free instant casino slots free play time at casinos! No Deposit Code Rtg Casinos slots gratis googlefreeslots, Free Signup Bonus No Deposit Casinos United States party city free no download slot play for fun Cirrus Casino Bonuses no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Games No Sign Up No Registering ffree online slot games no downloads play free slots for fun only Best Casinos With Promotions free slots bonus codes igt games download Players Only Bonuses minimum deposit $10 casino casino free came Casino Coupons download slot machines poker no deposite casino codes Usa Free Online Casinos No Money play for fun and free instant casino slots usa casinos no deposits Free Casino Money No Deposit slots gratis googlefreeslots, Free Monopoly Casino Downloads party city free no download slot play for fun All No Deposit Casinos Codes Rtg Casinos no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Freecasinobonuses ffree online slot games no downloads free rtg casino codes Golden Casino No Deposit Coupon Codes free slots bonus codes igt games download Pictures Las Vegas Slot Machines minimum deposit $10 casino casino free came Casino Bonus 1hour Free download slot machines poker no deposite casino codes Casinofreeslotsgames play for fun and free instant casino slots usa casinos no deposits List Of Casino Games slots gratis googlefreeslots, Golden Casino No Deposit Bonus Code party city free no download slot play for fun Pay Online Games For Free no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Texas Tea Slot Games ffree online slot games no downloads play free slots for fun only Cool Cat Casino Coupon Codes free slots bonus codes igt games download Party City Casino Promo Codes minimum deposit $10 casino casino free came Free Online Casino Signup Bonus Codes download slot machines poker no deposite casino codes Wheel Of Fortune Free Online play for fun and free instant casino slots usa casinos no deposits

Soaring Eagle Play Anyway

slots gratis real casino slot machines, New Club Player Casino No Deposit Codes party city free no download slot play for fun Play For 1 Hour Casino No Deposit no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casinos For Firsttime Players ffree online slot games no downloads play free slots for fun only

New Cool Cat Casino Bonus Codes

free slots bonus codes free casinos on line hour play Play Free Slots Online For Free Free Casino Games minimum deposit $10 casino casino free came Us No Deposite Casinos download slot machines poker "aladin online casino" Casino 1 Hour Free No Deposit Required play for fun and free instant casino slots usa casinos no deposits Download Free Monopoly Game slots gratis googlefreeslots, Slots For Free party city free diamond slot machine games Free No Deposit Casinos For Usa Players no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play Free Vegas Slots ffree online slot games no downloads play free slots for fun only Free Slot Cash No Deposit free slots bonus codes igt games download Free Chip Coupon Online Casinos minimum deposit $10 casino casino free came Play Fun Slot Machine Free download slot machines poker no deposite casino codes Free Hoyle Casino 2010 Download play for fun and free instant casino slots

usa casinos no deposits

Play For Fun Casino Games Slots slots gratis real casino slot machines, Free No Deposit Codes Casinos party city free no download slot play for fun Casino No Depoait And Code no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Slots On Line ffree online slot games no downloads play free slots for fun only New Online Casinos No Deposit Us Welcome free slots bonus codes igt games download Atlanta Online Casinos Play For Real Money Free minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free Spins Casino Usa download slot machines poker no deposite casino codes New Rtg No Deposit play for fun and free instant casino slots usa casinos no deposits Online Casinos That Really Pay Out slots gratis googlefreeslots, Play Frog Prince Free Slots party city free diamond slot machine games Play Free Slot Machines Casino Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. 10 Dollar Deposit Casino ffree online slot games no downloads play free slots for fun only Hot Shot Casino Online free slots bonus codes igt games download Free Online Slots With Bonus minimum deposit $10 casino casino free came Online Casino Free Money Coupon download slot machines poker "aladin online casino" Play Cleopatra Online play for fun and free instant casino slots usa casinos no deposits Online Casino No Deposit Bonus Blogs slots gratis googlefreeslots, Free Slots And Bingo party city free diamond slot machine games No Download Free Online Slot Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Usa Casino ffree online slot games no downloads play free slots for fun only Earn Money Online Casino

free slots bonus codes

free casinos on line hour play Best No Deposit Casino Deals minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free No Deposit Us Casino download slot machines poker no deposite casino codes Download Slot Machines Poker play for fun and free instant casino slots usa casinos no deposits

Power Beat Casino

slots gratis real casino slot machines, Free Ben Slots party city free no download slot play for fun Free On Line Cacino Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free No Deposit No Downloading Slots ffree online slot games no downloads play free slots for fun only Free Play Casino free slots bonus codes igt games download Top Online Casinos Nodeposit minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free Play Slots download slot machines poker no deposite casino codes Free Money To Gamble play for fun and free instant casino slots usa casinos no deposits Brand New No Deposit Casinos slots gratis googlefreeslots, Online Gamble Usa Paypal party city free no download slot play for fun Wild Vegas Casino Code No Deposit no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Flash Casino Games ffree online slot games no downloads play free slots for fun only Online Casino Free Trial free slots bonus codes igt games download No Deposit Free Money Promotions Casino minimum deposit $10 casino casino free came Casinos In Ok download slot machines poker no deposite casino codes Newest No Deposit Code Party City play for fun and free instant casino slots free play time at casinos! Slots Of Vegas Coupon Codes slots gratis googlefreeslots, Best Played Slots In Atlantic City party city free no download slot play for fun Texas Hold Em Game no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Casino Games For Real Money ffree online slot games no downloads play free slots for fun only 10 Dollar Deposit Casinos Usa free slots bonus codes igt games download Wild Wofe Slot minimum deposit $10 casino casino free came Free Fun Slots download slot machines poker no deposite casino codes Coolcat Casino Deposit Bonus Codes play for fun and free instant casino slots usa casinos no deposits Virtual Casino Group Bonus slots gratis googlefreeslots, Online Casinos With Pay Pal party city free no download slot play for fun Nodeposit Casino Couponcode no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Coolcat Casino Codes No Deposit ffree online slot games no downloads play free slots for fun only Free Online Slots No Registration free slots bonus codes igt games download New Slots Of Vegas Casino No Deposit Bonus Code minimum deposit $10 casino casino free came Csasino Slot Free Play download slot machines poker no deposite casino codes Casino Games No Download play for fun and free instant casino slots usa casinos no deposits New Online Casinos slots gratis googlefreeslots, Free Bonus Slots No Downloads party city free no download slot play for fun Free Online Slots That Pay Cash no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Cleoprata Slot Game ffree online slot games no downloads play free slots for fun only Stripping Online Games free slots bonus codes igt games download Best Slot Casino Las Vegas minimum deposit $10 casino casino free came Freeslotgames download slot machines poker no deposite casino codes No Deposit Casino Canada play for fun and free instant casino slots

usa casinos no deposits

No Deposit Bonuses Rtg slots gratis real casino slot machines, Free Instant Credit Signup Casino Bonuses party city free no download slot play for fun Free Slots Mama no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Slow Machine Monopoly ffree online slot games no downloads play free slots for fun only Casinos With Free Tournaments free slots bonus codes igt games download Minimum 10 Deposit Casinos minimum deposit $10 casino casino free came Onlinevegas.com Bonus Coupons download slot machines poker no deposite casino codes Rtg Casino Codes play for fun and free instant casino slots usa casinos no deposits Freeon Line No Down Load Casino Games slots gratis googlefreeslots, Play Sun And Moon Free party city free no download slot play for fun Free Sign Up Money To Gamble no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slot Machine Games With Bonus Free ffree online slot games no downloads

free rtg casino codes

Us Players No Download Casinos free slots bonus codes free casinos on line hour play New Online No Download Free Play Casinos minimum deposit $10 casino casino free came Free Chips No Deposit Required download slot machines poker no deposite casino codes Latestcasinobonus play for fun and free instant casino slots usa casinos no deposits Free Fun Slots No Download slots gratis googlefreeslots, Play Frog Prince Slot Machine Game For Free party city free no download slot play for fun Who Accept Paypal Payment For Casino Usa no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slotscasinofreegames.com ffree online slot games no downloads play free slots for fun only Usa Online Casinos Free No Deposit Bonus And Tournaments free slots bonus codes igt games download Free No Deposit Free Money For Usa Players minimum deposit $10 casino casino free came Play Slots Online For Free download slot machines poker no deposite casino codes I Would Like To Play Free Slot Machine Games play for fun and free instant casino slots free play time at casinos! No Depsit Casino Blog slots gratis googlefreeslots, Canada Casino No Deposit Sign Up Bonuses party city free no download slot play for fun Casino Free Money no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Play For Fun Slot Machines ffree online slot games no downloads play free slots for fun only Make Money Free Online Slots free slots bonus codes igt games download Windows Free Casino minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Play Free Slot Machine download slot machines poker no deposite casino codes Free Rtg Casino No Dep play for fun and free instant casino slots usa casinos no deposits Paypal Canada Casino slots gratis googlefreeslots, Free Bonus Casinos party city free no download slot play for fun Free Play Casino No Deposit Slots no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Video Slots Online ffree online slot games no downloads play free slots for fun only Sun And Moon Slot Free free slots bonus codes igt games download Sun And Moon Slots minimum deposit $10 casino casino free came Frog Prince Slot Game download slot machines poker "aladin online casino" Slots For Fun No Down Loading play for fun and free instant casino slots usa casinos no deposits No Deposit Casinos Usa slots gratis googlefreeslots, No Deposit At All United States Casinos party city free no download slot play for fun Realvegas no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Sun And Moon Slots ffree online slot games no downloads play free slots for fun only Free Slot Games Without Downloading free slots bonus codes igt games download Free Play 9 Line Slot Machines minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Slots Flash download slot machines poker no deposite casino codes Microgaming No Deposit Casinos play for fun and free instant casino slots usa casinos no deposits Newest Casinos slots gratis googlefreeslots, Las Vegas Casino Games party city free no download slot play for fun Playtech Casinos no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Allslots Free ffree online slot games no downloads play free slots for fun only Free Slot Machine Gambling free slots bonus codes igt games download Download Free Casino Fun Play minimum deposit $10 casino casino free came Free Slot Machines To Play download slot machines poker "aladin online casino" Free Slots On Google play for fun and free instant casino slots free play time at casinos! Casino Coupon Free Money Online slots gratis googlefreeslots, No Deposit Codes party city free diamond slot machine games Freeslots.com no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Bonus No Deposite Casino ffree online slot games no downloads play free slots for fun only No Deposit Cash Casino Usa free slots bonus codes igt games download Sportbetting Free Bonus No Deposit minimum deposit $10 casino casino free came Free Bonus Slot No Download download slot machines poker no deposite casino codes Fun Free Slots No Download play for fun and free instant casino slots

usa casinos no deposits

Free Games With Free Sign Up Bonus slots gratis real casino slot machines, Free Money Slots And Poker party city free no download slot play for fun Cirrus Casino Coupon Code no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. 1 Hour Free Play No Deposit Online Casinos ffree online slot games no downloads play free slots for fun only Free Slot Machines Play For Free free slots bonus codes igt games download Cirrus No Deposit Bonus Codes minimum deposit $10 casino casino free came The Munsters Free Slots download slot machines poker no deposite casino codes Freechips New Casinos play for fun and free instant casino slots usa casinos no deposits Play Free Slots With No Download And No Sign Up slots gratis googlefreeslots, Wheel Of Fortune With No Down Loading And Play For Free party city free no download slot play for fun Ben10 Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Elvis Slots ffree online slot games no downloads free rtg casino codes Instant Free Play Money Casino

free slots bonus codes

free casinos on line hour play Super Slots No Deposit Coupon minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Casino Slots Picture Free Download download slot machines poker no deposite casino codes Australian Virtual City Casino play for fun and free instant casino slots free play time at casinos! Real Vegas Casino Bonus Free Money.com slots gratis googlefreeslots, No Down Loads Free Slots party city free no download slot play for fun Us Online Casinos No Deposit Bonus no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Casinos No Deposit Free Chip Us Welcome ffree online slot games no downloads play free slots for fun only Online Texas Tea Slots Free free slots bonus codes igt games download Play Free Texas Tea Slot Game minimum deposit $10 casino casino free came Slot Machines Play For Fun download slot machines poker "aladin online casino" Free Chip No Deposit Casinos play for fun and free instant casino slots usa casinos no deposits Free Bonus Coupons No Deposit slots gratis googlefreeslots, Frog Games party city free no download slot play for fun
Free Rtg Casino Codes no deposit coupon codes instant play free fun slots no download slots machine Free Slots Machines On Line Com ffree online slot games no downloads play free slots for fun only Free Online Casino Games No Download free slots bonus codes igt games download Casino Online Tournaments minimum deposit $10 casino casino free came Casino Cleopatra Free download slot machines poker no deposite casino codes Play Free Cleopatra Slot Machine Online play for fun and free instant casino slots usa casinos no deposits Us Casinos slots gratis googlefreeslots, Free Play Slots Power Real party city free diamond slot machine games Free Casino Downloads For Fun
no deposit coupon codes instant play free fun slots no download slots machine Newest Casino Codes Free Money ffree online slot games no downloads play free slots for fun only

Us Casinos Online With No Deposit Bonus

free slots bonus codes free casinos on line hour play No Deposit Bonus Blog Codes minimum deposit $10 casino casino free came Free Online Slot Machine Games download slot machines poker no deposite casino codes No Deposit Slots Of Vegas Casino Coupon Code play for fun and free instant casino slots free play time at casinos! No Deposit Free Money Slots United States slots gratis googlefreeslots, Casino Online Real Money party city free no download slot play for fun Free Bonus Casino Game no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Pokermachinegames ffree online slot games no downloads play free slots for fun only Free Usa Slots free slots bonus codes igt games download Superslots For Fun minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free No Deposit Casinos Top 100 download slot machines poker "aladin online casino" Free Gamesslot Casino play for fun and free instant casino slots usa casinos no deposits

Free Casinos On Line Hour Play

slots gratis real casino slot machines, Instant Poker Bonus No Deposit party city free no download slot play for fun No Deposit Code Club Player Casino
no deposit coupon codes instant play free fun slots no download slots machine Download Free Slot Machines ffree online slot games no downloads free rtg casino codes Free Casinos Codes free slots bonus codes igt games download 1 Hour Free Casino Play Us Players minimum deposit $10 casino casino free came No Deposit Free Money Slots download slot machines poker no deposite casino codes Virtual Casino No Deposit Bonus Code play for fun and free instant casino slots free play time at casinos!

Downloading Monopoly For Free

slots gratis real casino slot machines, Pay Pal Casino Usa party city free no download slot play for fun Play Free Igt Slots no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Games No Download ffree online slot games no downloads free rtg casino codes Free Online Slot Machines No Download free slots bonus codes igt games download Wheel Of Fortune Online Free Slot minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Casino Games download slot machines poker no deposite casino codes Slots Cleopatra Casino play for fun and free instant casino slots usa casinos no deposits Free Vidio Slot Machines slots gratis googlefreeslots, Usa No Deposit Free Money Flash Casinos party city free no download slot play for fun No Deposit For Cirrus Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Igt Slot Machines ffree online slot games no downloads play free slots for fun only Free Practice Casinos free slots bonus codes igt games download Casino Download Free Money No minimum deposit $10 casino casino free came No Download Cleopatra Online Free Slots download slot machines poker no deposite casino codes Play Free Slots Mirage Casino play for fun and free instant casino slots usa casinos no deposits Forum Coupon Code Slot Of Vegas slots gratis googlefreeslots, Cirrus Free Coupn Codes party city free no download slot play for fun Casinos Still Accepting Us Players no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Slot Games ffree online slot games no downloads play free slots for fun only Free Games Casino Play free slots bonus codes igt games download Free Flash Casino Slots minimum deposit $10 casino casino free came Free Taxas Tea Slots download slot machines poker no deposite casino codes No Registration Free Online Slot Machines play for fun and free instant casino slots usa casinos no deposits No Deposit Free Play Casino Usa Players slots gratis googlefreeslots, Leopard Spots Slots
party city rtg no deposit forums, Monopoly Casino Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposits ffree online slot games no downloads free rtg casino codes Free Games No Download Required

free slots bonus codes

free casinos on line hour play Free Online Vegas Slot Machines minimum deposit $10 casino casino free came Games Free download slot machines poker no deposite casino codes Slots Nut No Deposit Codes play for fun and free instant casino slots usa casinos no deposits No Download Blackjack Online Casino No Deposit slots gratis googlefreeslots, Free Cleopatra Slots Online party city free no download slot play for fun Promotional Casino Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Bonus Slot Machines ffree online slot games no downloads play free slots for fun only New Bonuses Online Casino No Deposit free slots bonus codes igt games download Sun Andmoon Casino Game minimum deposit $10 casino casino free came Las Vegas Slot Coupons download slot machines poker "aladin online casino" Play Free Online Slots play for fun and free instant casino slots free play time at casinos! Top Free Bonus Slots slots gratis googlefreeslots, Nodepositcasinobonuses party city free diamond slot machine games Where Can I Play Free Slot Machines Online no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Down Load Free Slot Games ffree online slot games no downloads play free slots for fun only No Deposit Flash Casino Bonuses free slots bonus codes igt games download Casino No Deposit Promotion Codes minimum deposit $10 casino casino free came No Deposit Code For Las Vegas Usa download slot machines poker "aladin online casino" Download Without Money Games play for fun and free instant casino slots usa casinos no deposits Free Rtg No Deposit Casinos slots gratis googlefreeslots, Play Casinos For Free Money And Get It With No Deposit party city free diamond slot machine games Free Download Ben 10 Game no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play For Free Frog Prince Slots ffree online slot games no downloads play free slots for fun only Usa On Line Casino That Takes Paypal free slots bonus codes igt games download Free Bonus No Deposit Las Vegas Usa Casino minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. No Deposit Bonuses Blackjack download slot machines poker "aladin online casino" Freeplay Online Slots play for fun and free instant casino slots usa casinos no deposits No Download Free Slot Machines slots gratis googlefreeslots, Free Bet No Deposit party city free diamond slot machine games Harrahs Games Online no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Play Usa Welcome Casinos ffree online slot games no downloads free rtg casino codes

The Newest Casinos On Line

free slots bonus codes free casinos on line hour play 1 Hour Free Play minimum deposit $10 casino casino free came Donwloadable Slots download slot machines poker no deposite casino codes Free Hoyle Casino Games play for fun and free instant casino slots usa casinos no deposits Slots Play Free No Download slots gratis googlefreeslots, On Line Slot Machine Double Diamonds party city free no download slot play for fun Online Casinos Usa no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Online Frog Prince Slot Game ffree online slot games no downloads play free slots for fun only Redeem Coupon No Deposit Slots Of Vegas free slots bonus codes igt games download Little Green Men Casino Game minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Online Casino Free Play Promotions download slot machines poker no deposite casino codes No Download No Deposit Casinos Free Welcome Bonus play for fun and free instant casino slots usa casinos no deposits Playersonly Free Casino Chips slots gratis googlefreeslots, Top Online No Deposit Casinos party city free no download slot play for fun Free No Sign Up Bonus no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Casinos Free Money Coupon Codes ffree online slot games no downloads play free slots for fun only Play Las Vegas Slots For Free free slots bonus codes igt games download New No Deposit Casino Coupons minimum deposit $10 casino casino free came Free Slots For Fun No Download No Registration download slot machines poker no deposite casino codes Chumash Casino Free Slots play for fun and free instant casino slots usa casinos no deposits Free Play Online Casinos Us Players slots gratis googlefreeslots, Casino Machines party city free no download slot play for fun Best Paying Casinos In Vegas no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Bonus Or Code ffree online slot games no downloads play free slots for fun only Casino Slot Machines For Sale free slots bonus codes igt games download Free Oklahoma Slots Online minimum deposit $10 casino casino free came Free Play For Fun Online Casinos download slot machines poker no deposite casino codes Machine Gasino Play For Fun play for fun and free instant casino slots usa casinos no deposits The Virtual Casino Bonus Codes slots gratis googlefreeslots, Legal Age To Gamble In The Usa party city free diamond slot machine games All Bonus In One Free Chips no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Coupon Code For Free Cash At Online Casino ffree online slot games no downloads free rtg casino codes Partycity Casino No Deposit Codes free slots bonus codes igt games download Usa Paypal Deposit Flash Casino minimum deposit $10 casino casino free came Download Free Little Green Men download slot machines poker no deposite casino codes Free Online Playboy Slot Machine play for fun and free instant casino slots usa casinos no deposits Slot Nuts Casino No Deposit Bouns slots gratis googlefreeslots, Free Bingo And Slots party city free no download slot play for fun Free Online Bonus Machines no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play Free No Download ffree online slot games no downloads play free slots for fun only Free Online Slot Games For Fun free slots bonus codes igt games download Bonus Code Casino minimum deposit $10 casino casino free came Free Golden Slot Machine download slot machines poker "aladin online casino" Slot Games Free play for fun and free instant casino slots usa casinos no deposits Free Canadian Slots slots gratis googlefreeslots, Winmoneyfree party city free no download slot play for fun
New Casinos That Offer Free Money To Play no deposit coupon codes instant play free fun slots no download slots machine Win Free Money ffree online slot games no downloads play free slots for fun only Play Free Bonus Keno free slots bonus codes igt games download Free Slot Machines Casino minimum deposit $10 casino casino free came Play Free Casinoslots Online download slot machines poker no deposite casino codes Free Virtual Slot Machines play for fun and free instant casino slots usa casinos no deposits Coolcat Casino Coupon Codes slots gratis googlefreeslots, Free Spins For Us Players party city free no download slot play for fun Free Igt Slots Offline Downloads no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slot Machine Free Game ffree online slot games no downloads play free slots for fun only Online Slot Game Free free slots bonus codes igt games download No Downloads Free Casino Games minimum deposit $10 casino casino free came Free Play Casinos download slot machines poker "aladin online casino" Free Fireball Slots play for fun and free instant casino slots usa casinos no deposits Casino No Deposit Bonuses Forum slots gratis googlefreeslots, Casino Fair Play party city free no download slot play for fun Vegas Free Slots No Download no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Real Vegas Online ffree online slot games no downloads play free slots for fun only Free Slots Machine No Download free slots bonus codes igt games download Online Free Slots Free Sign Up Bonus minimum deposit $10 casino casino free came Play Igt Slots For Fun download slot machines poker no deposite casino codes Free Casino Chips play for fun and free instant casino slots usa casinos no deposits Soaring Eagle Casino Free Games slots gratis googlefreeslots, Slot Games Online Free party city free no download slot play for fun Online Slots Usa Welcome no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Hoyle Casino ffree online slot games no downloads play free slots for fun only No Deposite Casino Code free slots bonus codes igt games download Free Spin Casino minimum deposit $10 casino casino free came Free Usa Flaash Casino download slot machines poker no deposite casino codes Casinos With No Deposits And Free Money play for fun and free instant casino slots usa casinos no deposits Simulate Casino slots gratis googlefreeslots, Free Casino Play In Usa party city free diamond slot machine games Free Monopoly no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Freeslot Cleopatra ffree online slot games no downloads play free slots for fun only No Deposit Rtg Casino Codes free slots bonus codes igt games download Free Clip Art Money Coupons minimum deposit $10 casino casino free came Flash Games download slot machines poker no deposite casino codes No Deposit Casino 2010 play for fun and free instant casino slots usa casinos no deposits Casinos Offline Fun Plays slots gratis googlefreeslots, Casino No Deposit Required Codes party city
free no download slot play for fun Wheel Of Fortune Slots Online Free no deposit coupon codes instant play free fun slots no download slots machine Free Monopoly Slots Download ffree online slot games no downloads free rtg casino codes So Hot Slot Machine free slots bonus codes igt games download No Download No Deposit Free Bonus Casinos minimum deposit $10 casino casino free came Free Usa Casinos Online Play On The For 1 Hour download slot machines poker no deposite casino codes Offline Casinos play for fun and free instant casino slots usa casinos no deposits No Deposit Online Freeplay Casino slots gratis googlefreeslots, Slotsnodownload party city free no download slot play for fun Casino Money Without Deposit no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Sign Up No Register Play Free Slots ffree online slot games no downloads play free slots for fun only Free No Download Casino Games

free slots bonus codes

free casinos on line hour play Free Online Slot Machines With Bonus minimum deposit $10 casino casino free came No Deposit Slots Of Vegas Casino Codes download slot machines poker no deposite casino codes Free No Download Casino Play Usa play for fun and free instant casino slots usa casinos no deposits Flash Monopoly slots gratis googlefreeslots, Desert Dollar Casino New No Deposit Codes party city free no download slot play for fun New No Deposit Bonus Blog no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Las Vegas Casino Games ffree online slot games no downloads play free slots for fun only Usa Casinos Free Slots Online free slots bonus codes igt games download 10 Deposit Minimum On Line Casino For Usa minimum deposit $10 casino casino free came Us Casino Forums Free No Deposit Cash Codes download slot machines poker no deposite casino codes Free No Download Casino Slot Machine play for fun and free instant casino slots usa casinos no deposits Play Cherry Master Online slots gratis googlefreeslots, Play Sun And Moon Slot Machine Online party city free no download slot play for fun Us Nodepositcasinos no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Flash Casino Bonus Us Players Accepted ffree online slot games no downloads free rtg casino codes Play Online Free Casino One Hour free slots bonus codes igt games download Coupon Codes For Cirrus Casino minimum deposit $10 casino casino free came Play With Free Money No Deposit Usa Casinos download slot machines poker no deposite casino codes Best Online Casinos For Us Players And Codes play for fun and free instant casino slots usa casinos no deposits Casino Free No Deposit Coupon Codes slots gratis googlefreeslots, Casino Free Slotsmachine Free Downloading party city free no download slot play for fun Free Casino Slot Machine no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Frog Prince Slot Game ffree online slot games no downloads play free slots for fun only Free Casino Slots No Downloading free slots bonus codes igt games download Wild Vegas No Deposit Coupon Codes minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free Nd Casino Bonuses download slot machines poker "aladin online casino" Free Casino Bonus Slot Games play for fun and free instant casino slots

free play time at casinos!

Casino Free Slots slots gratis google free instant play casino games 5 Deposit Casino party city free no download slot play for fun Free Fruit Slots Machine no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. On Line Casino For Money ffree online slot games no downloads play free slots for fun only Free Fun Slot free slots bonus codes igt games download Latest No Deposit Codes For Rtg Casinos minimum deposit $10 casino casino free came Play Free Casino Slots Online download slot machines poker no deposite casino codes Free Slots Online Usa play for fun and free instant casino slots usa casinos no deposits Free Instant Play Casinos slots gratis googlefreeslots, Free Slots No Download Allowed In The United States party city free no download slot play for fun No Deposit Bonus Codes For Online Casinos
no deposit coupon codes instant play free fun slots no download slots machine Indian Dreaming Slot Game Free Download ffree online slot games no downloads free rtg casino codes Bingonodeposit free slots bonus codes igt games download Casino Slot Offline minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free No Download Slot Machines download slot machines poker no deposite casino codes Beat Casino Bonus play for fun and free instant casino slots usa casinos no deposits Free Tournaments No Deposits slots gratis googlefreeslots, Casino Promotion Free No Deposit party city free diamond slot machine games United States Online Casino No Cash Deposit no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casino ffree online slot games no downloads play free slots for fun only Online Casinos Accepting Us Players free slots bonus codes igt games download Slot Machines Game For Fun And Download. minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Freeonlinecasinogames download slot machines poker no deposite casino codes Scot Land Casino play for fun and free instant casino slots usa casinos no deposits New Casino No Deposit Required slots gratis googlefreeslots, Onlin Ru Free Games party city
free no download slot play for fun Riverbelle Casino no deposit coupon codes instant play free fun slots no download slots machine Free Play For Fun Online Casino Slots Bonus ffree online slot games no downloads play free slots for fun only Casinos With Hour Of Free Play free slots bonus codes igt games download Slot Machine Free Online minimum deposit $10 casino casino free came A To Z No Deposit Casinos download slot machines poker no deposite casino codes Free Slot Machines To Play That Are Like Las Vegas play for fun and free instant casino slots usa casinos no deposits Free Yahoo Casinos No Download slots gratis googlefreeslots, Onlinecasinobonuscodes party city free diamond slot machine games Slots Free Online no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Top Free Slots ffree online slot games no downloads play free slots for fun only Download Wheel Of Fortune Online Free free slots bonus codes igt games download Free Slots An Poker Games No Loading minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Vegasslotsfree download slot machines poker no deposite casino codes Partycitycasino play for fun and free instant casino slots usa casinos no deposits Online Casino With Free Cash Sign In slots gratis googlefreeslots, Usa No Deposit Bomus Cainos party city free no download slot play for fun 10 Dollar Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Free Sign Up Money Casinos ffree online slot games no downloads play free slots for fun only Free Games To Play free slots bonus codes igt games download 777 Slots Free No Down minimum deposit $10 casino casino free came Freecherry Casinoslots.com download slot machines poker no deposite casino codes Free Poker No Download No Register play for fun and free instant casino slots usa casinos no deposits Casino Promotion slots gratis googlefreeslots, Free Poker Machine Games No Download party city free diamond slot machine games No Download Casinos Fun Play no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casino Slots Free Download Play For Fun ffree online slot games no downloads play free slots for fun only Latest Casino No Deposit Codes free slots bonus codes igt games download Free Slots With Bonus Rounds For Fun minimum deposit $10 casino casino free came 7 Sultans Casino download slot machines poker no deposite casino codes Free Bets No Deposit Sportsbooks play for fun and free instant casino slots usa casinos no deposits Alljackpot Casino slots gratis googlefreeslots, Free Offline Casino Slot Games party city free no download slot play for fun Play Slots For Free Canadian Casinos no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Free Play Usa Casino ffree online slot games no downloads play free slots for fun only Play For Fun Cherry Master free slots bonus codes igt games download One Hour Free Play Bonus Casino minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Play Lucky Lady download slot machines poker no deposite casino codes Free Bonus Signup Casinos play for fun and free instant casino slots usa casinos no deposits Easy Street Slot Machine slots gratis googlefreeslots, Online Slot Machines For The United States party city free diamond slot machine games
Casino Windsor Play For Fun no deposit coupon codes instant play free fun slots no download slots machine Cleopatra Casino Slot ffree online slot games no downloads play free slots for fun only Casino Card Game free slots bonus codes igt games download Free Cleopatra Casino Slots minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Free Slot Machines Games Vagas Downloads download slot machines poker no deposite casino codes Legal Usa Online Casinos play for fun and free instant casino slots usa casinos no deposits Cirrus Casino No Deposit Codes slots gratis googlefreeslots, New Free Casino Chip Bonuse party city free no download slot play for fun Wild Vegas Online Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Bonus Codes For Usa Friendly Casinos ffree online slot games no downloads play free slots for fun only Free Pratice Slot Machine free slots bonus codes igt games download Play Free Casino Games Slots No Download minimum deposit $10 casino casino free came Roullete download slot machines poker no deposite casino codes Apex Slot Machine Games Free Download play for fun and free instant casino slots free play time at casinos! Free Slot Machine Play With No Downloads slots gratis googlefreeslots, No Deposit Casino Bonus Usa Accepted party city free no download slot play for fun Slots Of Vegas Casino Bonus Codes
no deposit coupon codes instant play free fun slots no download slots machine No Deposit Casino Free Money List ffree online slot games no downloads play free slots for fun only Hollywood Casino Pa free slots bonus codes igt games download Free No Deposit Casinos For Usa minimum deposit $10 casino casino free came Wild Vegas Bonus Codes download slot machines poker no deposite casino codes Indiana Live Casino play for fun and free instant casino slots usa casinos no deposits Free Slots With No Download slots gratis googlefreeslots, Golden Casino party city free no download slot play for fun Redem Coupon Casino Bonus No Deposit no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slot Coupon Code Free ffree online slot games no downloads

play free slots for fun only

Coupon Code Bonuses For Online Casinos free slots bonus codes free casinos on line hour play Free Flash Action Games minimum deposit $10 casino casino free came Free Cleopatra Games download slot machines poker no deposite casino codes Free Online Texas Tea Casino Game play for fun and free instant casino slots usa casinos no deposits Free Casino Cash slots gratis googlefreeslots, No Download Free Games party city free no download slot play for fun Milk Money Slot Machine no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slots Online Gratis Free ffree online slot games no downloads free rtg casino codes Real Money Casino free slots bonus codes igt games download Bet Royal Online Casino minimum deposit $10 casino casino free came Casinoonlineslots download slot machines poker no deposite casino codes Free Frog Prince Slot play for fun and free instant casino slots usa casinos no deposits Free Slots In Vegas slots gratis googlefreeslots, Casino Free Slots No Download party city free no download slot play for fun Cleopatra Free Slot no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Wheel Of Fortune Slots No Registration ffree online slot games no downloads play free slots for fun only All Cirrus Casino No Deposit Bonus Codes free slots bonus codes igt games download Play Bunus Slot Machines For Free minimum deposit $10 casino casino free came Free Funny Games download slot machines poker no deposite casino codes No Deposit Casino Free Chips play for fun and free instant casino slots

usa casinos no deposits

Aladdin Online Casino slots gratis real casino slot machines, Coupon Codes Slots Vegas No Deposit party city free no download slot play for fun
Online Casinos Play For Fun no deposit coupon codes instant play free fun slots no download slots machine Play Wheel Of Fortune Casino ffree online slot games no downloads play free slots for fun only Play Blackjack Using Paypal free slots bonus codes igt games download Free Flaming 7 Slot Machine minimum deposit $10 casino casino free came Cirrus Uk Casino Bonus Codes download slot machines poker no deposite casino codes Playing Monopoly Slots On Line Free play for fun and free instant casino slots usa casinos no deposits Coupon Codes For Nfree Casino Money For 2010 slots gratis googlefreeslots, Free Slots Online No Downloading party city free no download slot play for fun Free Test Slot Machines no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Rtg Casino Bonuses ffree online slot games no downloads play free slots for fun only No Deposit Playtech List free slots bonus codes igt games download Las Vegas Free Slot Games minimum deposit $10 casino casino free came Free Slot Machine Game download slot machines poker no deposite casino codes United States Online Casinos play for fun and free instant casino slots usa casinos no deposits Brand New No Deposit Bonus Casinos slots gratis googlefreeslots, Play Free Leopard Spots Slot party city free no download slot play for fun 1 Hour Free Casinos
no deposit coupon codes instant play free fun slots no download slots machine Play Free Slot Machines With No Downloading Required ffree online slot games no downloads free rtg casino codes Online Casino Play Free For 1 Hour free slots bonus codes igt games download Paypal Games minimum deposit $10 casino casino free came Free Online Monopoly Slots Games download slot machines poker "aladin online casino" Freebonuscasinos play for fun and free instant casino slots

usa casinos no deposits

Slot Casino Play For Fun slots gratis real casino slot machines, Best Slots In Las Vegas Gambling party city free no download slot play for fun New Free Slot Casinos no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Monopoly Casino Slots Online ffree online slot games no downloads free rtg casino codes Slot Games free slots bonus codes igt games download Play Free Indian Dreaming Slots minimum deposit $10 casino casino free came Download Free Cherry Master Games download slot machines poker "aladin online casino" Free Slot No Deposits play for fun and free instant casino slots usa casinos no deposits Free Online Casinos With Wheel Of Fortune slots gratis googlefreeslots, Fun Casino party city free diamond slot machine games 1 Hour Free Play Online Casinos For United States no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Club Usa No Deposit Codes ffree online slot games no downloads play free slots for fun only Casino Free Download free slots bonus codes igt games download Free Casino Slot minimum deposit $10 casino casino free came Free Casinos That Make Money download slot machines poker no deposite casino codes Coupon Redeem Casino play for fun and free instant casino slots

usa casinos no deposits

Is Las Vegas Paying Out slots gratis google free instant play casino games Free Online Casino Slot Tournaments party city
free no download slot play for fun Free Slot Wheel Of Fortune no deposit coupon codes instant play free fun slots no download slots machine Codes For Las Vegas Casinos ffree online slot games no downloads play free slots for fun only Freevideoslots free slots bonus codes igt games download The Munsters Slot Machine minimum deposit $10 casino casino free came New Codes For Casinos In Usa download slot machines poker "aladin online casino" Newest Free Spins Casinos play for fun and free instant casino slots usa casinos no deposits Free Online Munster Slots

slots gratis

real casino slot machines, No Deposit Rtg Casino Coupon Codes party city free diamond slot machine games Cirrus Casino Free Money Code
no deposit coupon codes instant play free fun slots no download slots machine Sports Book Free Money Codes ffree online slot games no downloads free rtg casino codes Sportsbook Free No Deposit Bonus Code free slots bonus codes igt games download Free Casino Online And Offline minimum deposit $10 casino casino free came Free Casino Fun download slot machines poker no deposite casino codes Casinos With Free Cash That Have Monopoly Slot Game play for fun and free instant casino slots

usa casinos no deposits

Las Vegas Free Clip Art slots gratis google free instant play casino games No Deposit Denied Online Casino party city free no download slot play for fun Vegas Casinos Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Harrahs Free Online Casino Games ffree online slot games no downloads play free slots for fun only Double Diamond Wheel Of Fortune

free slots bonus codes

free casinos on line hour play Hoyle Casino 2010 Free Download minimum deposit $10 casino casino free came Free Online Game For Roulette download slot machines poker no deposite casino codes 10 Dollar Minimum Deposit Online Casino play for fun and free instant casino slots usa casinos no deposits Casinos With No First Deposit That Got Free Money slots gratis googlefreeslots, Las Vegas Online Coupons party city free diamond slot machine games Free Cherry Slot Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Download Slots For Fun ffree online slot games no downloads play free slots for fun only Golden Palace Casino free slots bonus codes igt games download Slot Machines Free No Downloading minimum deposit $10 casino casino free came Free Texas Tea Download download slot machines poker no deposite casino codes Casino No Deposit Bonus Codes play for fun and free instant casino slots free play time at casinos! Play Online Slots For Money slots gratis googlefreeslots, Free Cleopatra Online Slots party city free no download slot play for fun Free Online Slots no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casino Free Money Usa ffree online slot games no downloads play free slots for fun only No Deposit Caqsinos free slots bonus codes igt games download No Depositebonus Blog minimum deposit $10 casino casino free came Bonusesonline Slots download slot machines poker no deposite casino codes Australian Casinos play for fun and free instant casino slots usa casinos no deposits Free Monopoly Online slots gratis googlefreeslots, Free Online Slot Machines With Bonuses party city free no download slot play for fun Free Slot Ter no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Michigan Online Casino ffree online slot games no downloads play free slots for fun only Us Players Welcome Bonus No Deposit Casino free slots bonus codes igt games download Free Online Casinos Codes minimum deposit $10 casino casino free came Happy Slots Casino download slot machines poker no deposite casino codes Free Casino Slot Mashines play for fun and free instant casino slots usa casinos no deposits Free To Play Slot Machines With Free Spins slots gratis googlefreeslots, Casinos New Instant Play party city free no download slot play for fun Free Online Slot Games With No Download no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Party City Bonus ffree online slot games no downloads

play free slots for fun only

Play No Download Free Slot Machine Games free slots bonus codes free casinos on line hour play President Casino Online Play Slots minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Casino Games Slots download slot machines poker no deposite casino codes Cool Cat Casino Code play for fun and free instant casino slots free play time at casinos! Free Virtual Casino Game slots gratis googlefreeslots, Play Free Casino Slot Game Australia party city free no download slot play for fun New Online Casinos No Deposit Bonuses no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play Real Money No Deposite Casino ffree online slot games no downloads play free slots for fun only No Deposit Sportbets free slots bonus codes igt games download On Line Vegas Games minimum deposit $10 casino casino free came Game Slot Free Download download slot machines poker no deposite casino codes The Real Deal Slot Free Games play for fun and free instant casino slots usa casinos no deposits Aladdin Casino slots gratis googlefreeslots, Free Casino Cash Promo Codes party city free diamond slot machine games Free Chip Virtual Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Download Slot Machine Games Play Only ffree online slot games no downloads play free slots for fun only New No Deposit Bonus Casinos

free slots bonus codes

free casinos on line hour play Play Free Igt Casino Games minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Play Igt Slots Online download slot machines poker no deposite casino codes Sex Free Download play for fun and free instant casino slots usa casinos no deposits No Deposit Bonus Online Casino For United States Players slots gratis googlefreeslots, Usa Online Casino No Deposit Required party city free no download slot play for fun Free Poker No Downloads no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Casinos Sign Up Bonus ffree online slot games no downloads play free slots for fun only Latest No Deposit Casino Codes free slots bonus codes igt games download Free Casino Monopoly Slots minimum deposit $10 casino casino free came Free Slots No Download No Registration download slot machines poker no deposite casino codes Money Burn Slots play for fun and free instant casino slots usa casinos no deposits Bonus Slots slots gratis googlefreeslots, Free March Casino Codes party city free no download slot play for fun Usa Casino No Deposit Free Play
no deposit coupon codes instant play free fun slots no download slots machine Players Only On Line Casino ffree online slot games no downloads play free slots for fun only Online Casino 10 Free free slots bonus codes igt games download Free Chips Us Online Casinos minimum deposit $10 casino casino free came New Online Casino download slot machines poker no deposite casino codes Html Code Games play for fun and free instant casino slots usa casinos no deposits Play Free Casino Slots Machine slots gratis googlefreeslots, Slots Of Vegas Free Chip Codes party city free no download slot play for fun Cash Journey Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Play For Fun Spell Slot Game ffree online slot games no downloads free rtg casino codes Games Free To Play Now free slots bonus codes igt games download New Cirrus Bonus Codes minimum deposit $10 casino casino free came Free 1 Hour Slots download slot machines poker "aladin online casino" Download Free Slot Machine Games play for fun and free instant casino slots free play time at casinos! Slot No Download slots gratis googlefreeslots, Free Slots No Deposit Online party city free no download slot play for fun No Deposit Casinos Bonuscodes no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Usa Accepted Casinos ffree online slot games no downloads play free slots for fun only Virtual Casino No Deposit free slots bonus codes igt games download Horseshoe Casino Coupons minimum deposit $10 casino casino free came Casino Games Free download slot machines poker "aladin online casino" Free Uk Online Slots play for fun and free instant casino slots usa casinos no deposits Online Casinos With 1 Hour Free Play slots gratis googlefreeslots, Free Bonus Money Casinos party city free no download slot play for fun Rtg Casino Free Money no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Fucking Instant Free ffree online slot games no downloads play free slots for fun only Free Online Slots No Download free slots bonus codes igt games download 15 Dollar Deposit Casinos minimum deposit $10 casino casino free came Freeslotsmachine download slot machines poker no deposite casino codes Slots Of Vegas No Deposit Bonus Codes play for fun and free instant casino slots

free play time at casinos!

Sun Moon Casino Game slots gratis real casino slot machines, Free Slot Machine Games No Down Loads party city free no download slot play for fun Bonus Code For Las Vegas Usa Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. No Deposit Bonus Slots No Download ffree online slot games no downloads play free slots for fun only Slots Of Vegas Rtg Codes free slots bonus codes igt games download Free Slots Online With Bonus Games minimum deposit $10 casino casino free came Play Free Online Slot Machines Cleopatra 2 download slot machines poker no deposite casino codes Ffree Online Slot Games No Downloads play for fun and free instant casino slots usa casinos no deposits Free Slots Games slots gratis googlefreeslots, Free Ben10 Games party city free no download slot play for fun Play No Download Slots Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Online Casino Canada ffree online slot games no downloads play free slots for fun only No Deposit Canadian Casinos free slots bonus codes igt games download Top10 Casinos Online minimum deposit $10 casino casino free came Free And Safe Online Casino Games download slot machines poker no deposite casino codes Slot Machine Arrest In Texas play for fun and free instant casino slots usa casinos no deposits Us Player No Deposit Casino Bonus Microgaming slots gratis googlefreeslots, Play Free Monopoly Slots party city free no download slot play for fun Free Downloading Games no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casino With Nodeposit ffree online slot games no downloads play free slots for fun only Slot Cleopatra Casino free slots bonus codes igt games download Free Slot Machine Computer Games minimum deposit $10 casino casino free came Free Poker Machine Games No Downloads download slot machines poker "aladin online casino" Money To Burn Slots play for fun and free instant casino slots usa casinos no deposits Casino Spinning Games slots gratis googlefreeslots, Virtual City Free Bonus Codes party city free no download slot play for fun Free Slots No Downloads Or Sign In no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slots Of Vegas ffree online slot games no downloads play free slots for fun only Coolcat Casino Codes free slots bonus codes igt games download No Deposit Slot Machines minimum deposit $10 casino casino free came Cool Cat Casino Bonus Code download slot machines poker no deposite casino codes Free Holye Slots Games play for fun and free instant casino slots usa casinos no deposits Play Monopoly Online Free No Download slots gratis googlefreeslots, No Deposit Online Casino Codes Us Ok party city free no download slot play for fun No Deposit Slot For Real Money no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Casino Free Cash No Deposited ffree online slot games no downloads

play free slots for fun only

Funny Game Casino free slots bonus codes free casinos on line hour play Free Google Slot Games minimum deposit $10 casino Free on line slot machines no down load new online no deposit casino bonus 364. Play Igt Slot Games download slot machines poker no deposite casino codes Virtual Casino Coupon Code play for fun and free instant casino slots usa casinos no deposits Online Casino Minimum Deposit slots gratis googlefreeslots, Real Vegas Online Bonus Codes party city free no download slot play for fun New Online South Africa Casino No Deposit no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Slots Vegas Casino No Deposit Free Bonus Code ffree online slot games no downloads free rtg casino codes Play For Free Online Monopoly Slots 20 Lines free slots bonus codes igt games download Free Online Slots Play Now No Downloading No Credit Card minimum deposit $10 casino casino free came No Deposit Bonuses download slot machines poker "aladin online casino" Free Slots With No Deposit play for fun and free instant casino slots usa casinos no deposits Free Video Slot Games For Fun slots gratis googlefreeslots, Desert Dollar Bonus Code party city free no download slot play for fun Play Texas Tea Online For Free no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Ben 10 Free Download ffree online slot games no downloads

free rtg casino codes

Free Cherry Slots free slots bonus codes free casinos on line hour play 10 Dollar Buy In Casinos minimum deposit $10 casino casino free came Free Real Casino Slot Machines download slot machines poker no deposite casino codes Play Slots For Free No Download play for fun and free instant casino slots usa casinos no deposits Usa Friendly New No Deposit Casinos

slots gratis

real casino slot machines, Free Online Slot Games With No Download Cleopatra party city free no download slot play for fun No Deposit Bonus Blog no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Coupon Code Cool Cat ffree online slot games no downloads

play free slots for fun only

Casinos With Free Slot Tournaments free slots bonus codes free casinos on line hour play Free Slots No Downloads minimum deposit $10 casino casino free came Redeem Coupon Casino Cirus Casino download slot machines poker no deposite casino codes Stampede Slot Online play for fun and free instant casino slots usa casinos no deposits 7 Sultans Casino Download slots gratis googlefreeslots, Ben 10 Free Games party city free no download slot play for fun Free Downloadable Us No Deposit Casino no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Free Bones Casinos Us ffree online slot games no downloads play free slots for fun only Casino Slots For Fun free slots bonus codes igt games download Online Casinos No Deposit minimum deposit $10 casino casino free came Frog Prince Slots download slot machines poker no deposite casino codes One Hour Free Usa Casinos play for fun and free instant casino slots usa casinos no deposits Monopoly Free Download slots gratis googlefreeslots, Monoply Casino Game Online Free Play party city free no download slot play for fun Free Casino Player Codes no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. New Online Casinos Usa Welcome ffree online slot games no downloads play free slots for fun only Casinos Gratis free slots bonus codes igt games download Casino Bet Online minimum deposit $10 casino casino free came Flash Casino No Deposit Cash Codes Bonus download slot machines poker no deposite casino codes Monopoly Casino Download play for fun and free instant casino slots free play time at casinos!

Casino Slots Policeman

slots gratis real casino slot machines, New No Deposit Casino Online party city free no download slot play for fun Wheel Of Fortune Slot Machine no deposit coupon codes No deposit casino coupons new free no deposit casino bonus codes 73. Msn Free Slot To Play 4 Fun ffree online slot games no downloads play free slots for fun only Roullete Free Play free slots bonus codes igt games download No Deposit Gambling Forums minimum deposit $10 casino casino free came Free Slot Games For Fun download slot machines poker no deposite casino codes No Deposit Sign Up Bonus Usa Casinos play for fun and free instant casino slots usa casinos no deposits Uk Free No Download Slots slots gratis