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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sirina Keesara
Sirina.Keesara(a)ucsf.edu

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Joseph Fitchett
Joseph.fitchett@doctors.org.uk

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(more…)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

Seriously. London, Pluto.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Introduction

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

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

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

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

Sequence of Traumatic Events

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

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

Mental Health Issues after KR

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

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

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

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

Getting Away with Genocide

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

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

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

Conclusion

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

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

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

References:

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.

Image credit: Wikimedia Commons

Todays article comes to us from Matthew Rinaldi who discusses rising trends in childhood obesity.

Introduction

With the number of overweight under-5s estimated to hit 42 million this year (1), childhood obesity is an issue which has now reached pandemic proportions (2). Programmes that have begun to tackle the issue have shown success and should be expanded if we are to minimize the impact to global mortality that this global health issue threatens.

It is widely accepted that Global Health is the “health problems, issues, and concerns that transcend national boundaries […] and are best addressed by co-operative actions and solutions” (3). By establishing the current burden and causes of childhood obesity and showing that these affect the worldwide community, the case for actively reducing its impact should be clear.

Measuring Obesity in Children

The World Health Organization definition of obesity (4) uses the Body Mass Index to assess an adult’s level of obesity. An adult measurement over 25 kg/m2 is classified as overweight and over 30 kg/m2 is clinically obese. This classification was updated in 2000 to allow international comparison of child obesity worldwide (5). The charts are age- and sex-specific to allow for the fact that healthy body fat changes with age and differs between the genders.

(more…)

“Do not inquire the name of him who asks a shelter of you. The very man who is embarrassed by his name is the one who needs shelter.” (1)

As medical students in Israel, we were privileged to volunteer in an open clinic for refugees and asylum seekers in Tel-Aviv during the past year. The clinic is operated by Physicians for Human Rights (PHR), a non-governmental organization (NGO). This article will review the clinic’s activities, and within this framework we have conducted an interview with Iman Aghbariyya, the manager of the open clinic. Let us first understand the background of the current situation.

Refugees in Israel

The UNHCR’s (UN High Commissioner for Refugees) annual 2008 Global Trends report shows the number of people forcibly uprooted by conflict and persecution worldwide stood at 42 million at the end of last year. The total includes 16 million refugees and asylum seekers and 26 million people uprooted within their own countries (2).

Since 2007 there has been a dramatic increase in the number of refugees and asylum seekers arriving to Israel, mainly from Africa, following regional conflicts and humanitarian crises. Nowadays, about 17,000 reside in Israel (2), coming mostly from Erithrea (7000) and Sudan (5500), and the rest from other countries like the Ivory Coast and Congo. Nearly all asylum-seekers come to Israel through Egypt. Israel’s southern border is over 230km long and porous, only a low fence separating the two states. Asylum-seekers pay Bedouin guides hundreds of US dollars to get them to the frontier where they risk getting shot at by Egyptian border guards. According to UNHCR and NGOs in Cairo, in recent years hundreds have been wounded and detained while attempting to cross the border, several have been deported to their countries of birth, while others have been shot dead (3).

In Israel, under certain circumstances, regulations can allow asylum-seekers to work, and grant temporary protection and non-refoulement (a commitment not to force people back to where they came from). However, getting non-private medical treatment is a more complicated problem. Until their legal status is regulated, asylum-seekers are entitled to get emergency medical treatment but not to use the public healthcare system. Therefore, once in Israel, they are forced to receive their medical assistance from UNHCR and local NGOs, including Moked, Assaf, the African Refugee Development Centre (ARDC) and Physicians for Human Rights (PHR). Last year, the Israel medical association opened its own clinic, providing free primary treatment for refugees.

The Clinic

PHR-Israel was founded in 1988 with the goal of struggling for human rights, in particular the right to health, in Israel and the Palestinian territories. Today PHR runs five projects: the Palestinian territories project, the prisoners and detainees project, the migrant workers and refugees project, the project for the unrecognized villages of the Negev, and the residents of Israel project. In addition, PHR runs a mobile clinic in the Palestinian territories, and an open clinic in Tel Aviv that provides services for all within Israel who have no legal status and therefore no health insurance.

The entrance of the open clinic in Tel-Aviv

Since its foundation in 1998 about 20,000 patients have been treated by the open clinic. The clinic is run mostly by volunteers and operates on two levels. On the humanitarian level, the clinic aims to provide the best possible health services to all in need, including migrant workers, refugees, asylum seekers and other status-less persons lacking medical insurance; On the ideological level, the clinic leads the struggle to change policies and to apply the national health insurance law to the populations treated by the clinic.

For the thousands of refugees and asylum seekers arriving in Israel in 2006-2007 from Africa, the only address for medical treatment was PHR-Israel’s Open Clinic. The large number of refugees and asylum seekers made a significant impact, as the Open Clinic received over one hundred patients each evening, some with severe physical and emotional trauma.

Iman Aghbariyya has been running the open clinic for the past year. She first started to work at PHR 10 years ago, as application coordinator. She is very excited and proud of her work at PHR, managing a full time job alongside raising her 4 children. Over the years she served in different positions and before running the open clinic she ran the mobile women clinic, which promotes women health issues and provides medical care for women in villages with limited access to medical services.

Iman Aghbariyya during her work in the open clinic

Iman tells us that the clinic was founded after a migrant worker who suffered from an infected wound, died because he was afraid to seek medical care:

“About a year before the Clinic opened, a migrant worker from Ghana came to the ER suffering from a morass in the anal region. Due to his fear of seeking medical attention he had waited for almost two weeks, and only sought help when his situation became very serious. On intake in the ER he was suffering from severe infection and underwent surgery on him the same night, as well as ostomy surgery due to the severe compromising of the anal area. He was subsequently treated in the intensive care unit, and over the following two weeks underwent several operations due to worsening of his situation.

“He eventually died as the result of multisystem failure and the uncontrolled infection. The doctor treating him was horrified by his death. He met a friend who was active in the Association for Civil Rights in Israel and told her about this case, saying it was intolerable that in an advanced society someone should die from a minor illness just because they were too scared to seek medical attention in case they were deported. After calling several organizations, they were referred to PHR-Israel, which agreed to take up the challenge”.

The clinic is operating five days a week, three afternoons as a general clinic, once a week as a specialists’ clinic (gynecology, orthopedics and more) and one morning as a pediatric clinic. The clinic relies on volunteers who include about 160 family doctors, pediatricians, gynecologists and other specialists, 27 nurses, 54 medical students assisting with the triage, 50 translators, and 50 non-medical volunteers who assist with reception. In addition to the doctors coming to the clinic, about 30 doctors with a broad range of specializations receive patients in their own clinics, free of charge or with only a symbolic fee. Physiotherapy, acupuncture and dietician services are also provided.

In principle, each visit in the clinic costs the patient 10NIS (~2 Euros) but in fact, no charge is collected since even this sometimes can’t be afforded by the patients. Practically, no other choice is available to them because a similar visit in private clinic would cost around 500NIS (~100 Euros).

Funding is provided by many organizations, as well as private donors. The medicines are supplied by pharmaceutical companies (mainly drugs near expiry date), and from patients who no longer need the medications they have purchased.

The clinic cooperates with hospitals and other voluntary organizations in Israel. It is connected through agreements with various medical institutions that allow the patients to receive a variety of examinations, and other services, sometimes including surgery, free of charge or with significant discount. Tel-Aviv Sourasky Medical Center (Ichilov) donates a large amount of laboratory work, Assuta hospital provides discounted surgery and Sheba hospital at Tel Hashomer provides discounts for both examinations and treatments.

The Profile of the Patient Population

Until 2007 the most prominent group among those seeking help from the clinic were migrant workers, coming to Israel from developing nations to secure a future for their families. Since 2007, due to both local and global reasons, the profile of the patient population has changed. Along with activation of a deportation campaign against unauthorized migrant workers in Israel, the number of patients began to rise. The reason was mainly an increase in the number of asylum seekers and minors, arriving in Israel as a consequence of the political situation in their countries. Refugees and asylum seekers had accounted for a small proportion of patients in 2006, but during 2007 their relative weight rose steadily (3).

A detailed examination of the statistics for 2007 showed the increase in the number of refugees and asylum seekers, along the decline in number of migrants (taken with permission (3))

The patient population is comprised mainly of young and basically healthy people (ages 20-40). Many patients suffer from seasonal illnesses such as upper respiratory infections. Others suffer from other “simple” conditions such as urinary tract infections, but also from trauma following street fights. It is not all that surprising that many patients also suffer from psychological co-morbidities when you consider traumatic experiences they may have undergone on their way to Israel, and their life circumstances that entail much uncertainty and insecurity.

As an example of the cases the clinic deals with nowadays, Iman tells us about the following case:

“A 28 year old refugee from Erithrea, who arrived in Israel a few months prior to his visit, came to the clinic due to rectal bleeding, and abdominal pain. He was referred to the ER (which is obliged, by law, to attend to emergency cases). In the hospital, after a comprehensive workup, a malignant rectal tumor was diagnosed. He needed chemotherapy to reduce the size of the tumor before surgery. He would need further chemotherapy and radiation after surgery. The oncology ward refused to admit him for this expensive and long lasting treatment without a sponsor. Application for financial help to the UNHCR got a negative answer due to the high cost. Consequently he did not get the chemo treatment. The emergency treatment he finally received in the hospital included surgical resection of the tumor, and a stoma surgery. The patient is in need of stoma bags, costing over 1000 NIS (200 Euros) a month, and the clinic is trying to raise the money for his treatment.”

Similar stories of refugee patients can be found worldwide. According to Dr, Hadas Yaron, coordinator of the refugee project in AMNESTY Israel, UN agencies and human rights organizations share the opinion that the solution for the problem should be a joint action by the international community. The issue needed to be solved is not a war ending after several years, but a chronic situation of unending wars.

When we asked Iman what she wishes for the clinic, she answered that she wishes there will be no more need for it, and it will close. We join her in that wish.

Eyal Lotan and Eleana Meyers-Earon are medical students in their final year at Sackler School of Medicine, Tel-Aviv University, Israel.
elotan(at)post.tau.ac.il
eleana_m(at)hotmail.com

References

1. Victor Hugo, Les Miserables.
2. Data taken from United Nation High commissioner for Refugees (UNHCR). http://www.unhcr.org
3. Under your wing, refugees and asylum seekers at physicians for human rights-Israel’s open clinic. January 2008.

Background

Child health status in Pakistan is below acceptable levels, with 0.4 million under-five deaths each year and more than 500 children die every day before reaching age of one month [1-2]. The majority of under-five deaths are attributed to vaccine-preventable diseases, pneumonia, diarrhoea and under-nutrition [1-4]. [Table 1] Furthermore, progress in child health has been patchy and strategies must focus on cost-effective and practical interventions [5-7]. Evidence to support interventions in existing health system infrastructure, aimed to improve maternal and child health, is well documented [8-9] and these can be effectively incorporated into a child health and sanitation week.

1. Child Health and Sanitation Week

Child health and sanitation week was piloted in 2007 in two districts of Pakistan’s Punjab province. During the week, children were immunized and de-wormed; pregnant women vaccinated with tetanus toxoid; and health education sessions on exclusive breastfeeding, pneumonia and hygienic practices were arranged.

The author was with Department of Health District Nankana Sahib on volunteer medical student rotation during November 2007 and was involved in the implementation, operation and evaluation of first ever Child Health Week in Pakistan – piloted during November 2007 in two districts of Punjab province including Nankana Sahib – having 1.8 million habitants and located in central Punjab. Child health and sanitation week was piloted for first time with all available resources and every effort was made for its successful implementation by over 6000 health personnel and volunteers. A high level of commitment and ownership by one and all – in particular the district department of health– was the driving force behind the successful implementation of the project. Immunization and deworming were most successful parts of the activity. Backlogs in immunization coverage were successfully covered and almost all target children were de-wormed. However, health education during the event was not up to the expectations, the main reason being the lack of knowledge among health workers about communication skills. Haphazard supply of logistics, ineffective training and insufficient funds for field work were the other constraints. The week was again celebrated in two pilot districts in April 2008 and health education regarding diarrhea was imparted along with exclusive breast feeding and hygiene. In November 2008, the week was implemented in three districts of Punjab. Keeping in view the success of the project, the week was held in nine districts of Punjab in March 2009; and sanitation part of the project was focused by involving local governments and community development department and improving the health education sessions.

The week was again celebrated twice in 2008 focusing on immunization; deworming; and behavioral change regarding diarrhea, pneumonia, exclusive breast feeding and hygiene. Keeping in view the success of project, it was held again in 2009 and sanitation was also focused. The government plans to hold the weeks biannually and gradually increase number of districts.

2. Issues focused on in Child Health and Sanitation Week

Immunization and de-worming

Vaccine-preventable diseases remain the most common cause of childhood mortality with three million deaths each year and immunization can therefore significantly reduce mortality and morbidity among children [4, 10]. Diphtheria-Pertussis-Tetanus vaccine 3rd dose (DTP3) coverage is used usually to indicate coverage of immunization services [11]. Multiple doses of a vaccine are usually required to develop full immunity in a child against a particular disease and a high drop-out rate between first and last dose of a vaccine indicates low immunity. In Pakistan, DPT3 coverage is 83% and drop-out rate between DPT1 and DPT3 is 7% [12]. Protection from neonatal tetanus at birth in Pakistan via maternal immunization against tetanus is 80% [12-13]. Routine services under Expanded Program on Immunization are essential to maintain immunization coverage, in addition to which mass campaigns can play an important role [11, 14]. However, such campaigns have been used for polio and measles only at present. To fully vaccinate all children in appropriate age would require significantly increased effort [11, 14].

Large reductions in wasting, malnutrition and anemia world-wide that followed deworming contributed significantly to child survival and development [15-17]. A World Health Assembly resolution in 2001 set the goal of achieving 75% deworming coverage of population at risk by 2010 [18]. Although soil-transmitted helminthiasis is endemic in Pakistan, yet no deworming or helminth control program currently exists [19]. Implementation of any helminth control program requires strong links with existing interventions that are already in place to reach women and children [20].

Child health and sanitation week provided an integrated platform to cover backlogs in immunization, improve routine immunization coverage and carry out mass de-worming – it was the first ever large-scale effort for helminth control in Pakistan.

Behavioural changes

Breast feeding – in particular exclusively in first six months – is associated with reduced child mortality, morbidity and improved development [21-22]. Studies have shown that community interventions such as health education, peer counseling and support groups can promote breast feeding [23]. In addition, evidence suggests that behavioral change interventions in pneumonia and diarrheal disease, and family practices can significantly improve child survival and development [13, 24].

Community health education imparted by health workers regarding exclusive breastfeeding, pneumonia, diarrhoea and hygiene practices during child health and sanitation week provided an opportunity to encourage behavioral changes using existing infrastructure.

Sanitation

Around 10% of total disease burden worldwide could be prevented by improving water, sanitation and changing hygiene-related behaviors [25]. Viewing the importance of issue, UN General Assembly declared 2008 as international year of sanitation [26]. Pakistan made rapid progress in sanitation despite formidable odds and 40% of population gained access to improved sanitation source between 1990 and 2006 [26]. But still 68 million people have no access to an improved sanitation facility and 50 million practice open defecation; demanding an extra level of effort [26].

A special focus on sanitation was given during the recent child health and sanitation week by involving local governments and community development departments to provide resources, and spreading key hygiene messages for public awareness.

3. The Future

Child health and sanitation week provided a package for integrated delivery of health and nutrition interventions using the existing health system. It cost only 0.33 US$ per child per year [2] and was well-supported by government and donor agencies. In the future it could be made integrated into district annual plans with budget allocation from health sector.

The government plans to hold the weeks biannually and gradually increase the number of districts. Although most objectives of the project were successfully met but the following recommendations may help to get the better results in future:

· To increase validity of immunization coverage, vaccination cards should be provided to all the eligible children; and parents, especially those with poor socioeconomic background, should be motivated to keep the cards safe and accessible. If vaccines could be provided, TT immunizations should be given to all women of child-bearing age.

· Supervisory staff, especially mid-level health managers, should receive trainings for evaluation and use of data for action. Focused training programs should be organized for all the relevant health workers in communication skills and use of print material to motivate clients. The provincial and district health development centers can be utilized for that purpose.

· Logistics should be at hand at least fifteen days prior to child health week. The Information, Education and Communication (IEC) resources should be decentralized to district level and the promotional material should be tailored according to local needs.

· Sanitation wing of district health departments should be reorganized to make it fully functional and coordination with other departments should be increased at district level.

Child health and sanitation week appears to be an effective way to deliver interventions to improve child health with ultimate goal to prevent early childhood diseases in author’s view. Viability of project depends upon planning at district levels and sustainability of funding by donor agencies. To meet Millennium Development Goal (MDG) target to reduce under-five child mortality to two-thirds between 1990 and 2015, many countries will have to implement similar projects. Feasibility of conducting child health and sanitation week in Pakistan can serve as model for developing countries with similar infrastructure.

Umair Mushtaq is a final year MBBS student at Allama Iqbal Medical College in Lahore, Pakistan
umairmushtaq_aimc@yahoo.com

Acknowledgements

The author like to acknowledge the efforts of Erica and Mohsin Zia for their valuable comments on earlier versions of this article. I am highly grateful to Prof. Arif M. Siddiqui, MBBS, MD, MRCP, FRCP (London), FRCP (Edin), FRCP (Glasg) Chief Coordinator, Student Research Society and Professor of Medicine, Allama Iqbal Medical College, Lahore, Pakistan; Dr. M. Ashraf Majrooh, MBBS, DCH, MPH, FCPS Coordinator, Student Research Society and Associate Professor of Community Medicine, Allama Iqbal Medical College, Lahore, Pakistan; and Dr. Mushtaq Ahmad Shad, MBBS, DCH, MSc (Med Admin), FRSH (London) Executive District Officer Health, District Nankana Sahib, Punjab, Pakistan for their support and guidance.

References

1. United Nations Children’s Fund (UNICEF). The State of the World’s Children 2009. New York, NY: UNICEF, 2008.

2. United Nations Children’s Fund (UNICEF). Annual Report 2008: UNICEF Pakistan. Islamabad, Pakistan: UNICEF, 2009.

3. World Health Organization (WHO). World Health Statistics 2008. Geneva, Switzerland: WHO, 2008.

4. World Health Organization. The world health report 2004: changing history. Geneva, Switzerland: WHO, 2004.

5. Bhutta ZA, et al. Maternal and child health: is South Asia ready for change? BMJ, 2004, 328(7443): 816-9.

6. Haines A, Cassels A. Can the Millennium Development Goals be attained? BMJ, 2004, 329: 394–397.

7. Nullis-Kapp C. The knowledge is there to achieve development goals, but is the will? Bulletin of the World Health Organization, 2004, 82: 804–805.

8. Jowett M. Safe Motherhood interventions in low-income countries: an economic justification and evidence of cost effectiveness. Health Policy, 2000, 53: 201–228.

9. World Health Organization. The world health report 2002 – Reducing risks, promoting healthy life. Geneva, Switzerland: WHO, 2002.

10. Centre for Global Development. Making Markets for vaccines: from ideas to actions. Washington DC: Centre for Global Development, 2005.

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This article has been written as part of the partnership between The Lancet Student and Asian Medical Students’ Association International. The 30th Asian Medical Students’ Conference will be held next week in Taiwan on the theme of ‘Stigmatised Illnesses: To understand, to accept, and to change’. We look forward to hearing about the conference, look out for the conference blog and podcast next week! Alistair Hustig, the Secretary of Academcis – Asian Medical Students’ Association International, has written this fantastic article on the theme.

‘Stamping out Mental Health Stigma’, NHS.

Stigma. This one word often represents the most crucial element effecting people living with a wide range of illnesses. It negatively impacts efforts to treat and prevent disease, and adversely affects individuals’ quality of life. Many illnesses have a high prevalence of stigma including mental illnesses, cancer, leprosy, and sexually transmitted diseases. However, the type of stigma varies with different conditions. This article highlights some causes and differences of stigma associated with mental health and HIV, as well as successful strategies of reducing its impact.

Definitions of stigma encompass social identity (deviance from what is normal), power discrepancies (that allow discrimination), and discrediting attributes that result in devaluation of people living with illnesses, such as those above (1,2,3). This often manifests itself in an external sense as discrimination, hatred, intolerance, rejection, and exclusion. However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame, all of which are preyed upon when someone stigmatises (3,4). Stigmatisation can also extend to family, friends, and even to institutions and clinics which themselves perpetuate stigma. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.

People living with Mental Illness
People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression is a leading cause of disability effecting 121 million people worldwide (5). Schizophrenia affects millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are receiving appropriate therapy (5). These figures suggest that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness (6); or people with depression are dangerous, and ‘schizophrenics’ are violent (6,7) remains embedded in public opinion. These views are less shared with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the aetiology, pathophysiology, and successful treatments are well known. The fear of the unknown may therefore contribute to stigma being ingrained in an illness. As a result people with the illness are afraid of disclosing to family and friends, and do not seek help where it would be of benefit (6). Health practitioners, even those in the field of mental health can also stigmatise through intensive use of language and labelling. Some are more empathic and understanding of the nature of the illnesses, but some practitioners continue to define their patient by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour (7). This labelling may plague the patient as a ‘life sentence’ (7) reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties (8), ultimately ruining any chance of normality.

People living with HIV
It is estimated that around 33 million people worldwide are infected with HIV, with the majority in low- and middle-income countries (9). Of these, only 3 million were receiving appropriate anti-retroviral therapy as at December 2007 (9). Again one of the biggest issues preventing uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness. Bos and colleauges (10) propose a model for stigmatisation of people living with HIV. They describe how perceived contagiousness (everyday contact, not just sex), perceived seriousness (life-threatening), personal responsibility (unsafe sex) and norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use) contribute to increase fear and anger while decreasing pity for people living with the disease. Stigma also surrounds certain groups at increased risk, such as homosexuals, intravenous drug users, and sex-workers. This further stigmatises people living with HIV leading to amplified discrimination and negative social responses. As a result, people living with HIV have a decreased quality of life and are less likely to seek testing, treatment, and counselling, or disclose their status to potential support providers. This can result in advanced presentations with high viral loads, low CD4 counts, and opportunistic infections.

Strategies for Reducing Stigma
The need to address stigma is paramount in order to reduce prevalence and thus burden of illness (e.g. curbing the HIV epidemic), and increase treatment uptake. For mental illnesses, in particular depression, Barney and colleagues (6) suggest that blaming, avoiding, and labelling people living with mental illnesses must be addressed. Accurate knowledge and portrayals of survival and recovery, as well as the true risk to the community for these health conditions needs to be expressed by all means possible, especially the media.

Public disclosure of HIV status has been shown to have a beneficial impact to both the individual and the surrounding community (11). Individuals are often very scared and describe this as the most difficult and dangerous thing to do. Post-disclosure they feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives (11). To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from community members. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV (11) and mental illness (12), which have shown improved attitudes among high school students to those living with the illness. Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.

Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. The case of universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma (13). Wolfe and colleagues (13) demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.

Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.

Alistair Hustig, hust0007@flinders.edu.au
Secretary of Academics – Asian Medical Students’ Association International
Australian Medical Students’ Association Councillor
Graduate Entry Medical Programme Year II – Flinders University, Adelaide, South Australia
Bachelor of Medical Science – Flinders University, Adelaide, South Australia

References
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13. Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, Iacopino V, Heisler M. The Impact of Universal Access to Antiretroviral Therapy on HIV Stigma in Botswana. American Journal of Public Health, 2008; 98(10): pp. 1865-71.