“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.

11. Hill Z, Kirkwood B, Edmond K. Family and community practices that promote child survival, growth and development: a review of the evidence. Geneva, Switzerland: WHO, 2004.

12. World Health Organization and United Nations Children’s Fund. WHO/UNICEF Review of National Immunization Coverage 1980-2007: Pakistan. Geneva, Switzerland: WHO & UNICEF, 2008.

13. Griffiths U, Wolfson L, Quddus A, Younus M, Hafiz R. Incremental cost-effectiveness of supplementary immunization activities to prevent neo-natal tetanus in Pakistan. Bulletin of the World Health Organization, 2004, 82: 643-651.

14. World Health Organization. State of the world’s vaccines and immunization. Geneva, Switzerland: WHO, 2002. (WHO/V&B/02.21).

15. Stoltzfus RJ, et al. Effects of the Zanzibar school-based deworming program on iron status of children. American Journal of Clinical Nutrition, 1998, 68: 179–186.

16. Stoltzfus RJ, et al. Malaria, hookworms and recent fever are related to anaemia and iron status indicators in 0- to 5-y old Zanzibari children and these relationships change with age. Journal of Nutrition, 2000, 130: 1724–1733.

17. Stoltzfus RJ, et al. Low dose daily iron supplementation improves iron status and appetite but not anemia, whereas quarterly anthelminthic treatment improves growth, appetite and anemia in Zanzibari preschool children. Journal of Nutrition, 2004, 134:348–356.

18. World Health Organization. Schistosomiasis and soil-transmitted helminth infections. Resolution WHA54.19. Geneva, Switzerland: WHO, 2001.

19. World Health Organization. Progress report on number of children treated with anthelminthic drugs: an update towards the 2010 global target. Weekly epidemiological record 2008, 83: 237–252. (http://www.who.int/wer)

20. World Health Organization. Report of the third global meeting of the partners for parasite control: Deworming for Health and Development: Geneva, 29–30 November 2004. Geneva, Switzerland: WHO, 2005. (WHO/CDS/CPE/PVC/2005.14)

21. Leon-Cava N, et al. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington, DC: Pan American Health Organization, 2002.

22. World Health Organization. The optimal duration of exclusive breastfeeding: results of a WHO systematic review. Geneva, Switzerland: WHO, 2001.

23. Green CP. Improving breastfeeding behaviours: Evidence from two decades of intervention research. Washington, DC: Academy for Educational Development, 1999.

24. World Health Organization. The World health report: 2005: make every mother and child count. Geneva, Switzerland: WHO, 2005.

25. World Health Organization. Safe water, better health: costs, benefits and sustainability of interventions to protect and promote health. Geneva, Switzerland: WHO, 2008.

26. World Health Organization and United Nations Children’s Fund Joint Monitoring Program for Water Supply and Sanitation. Progress on drinking water and sanitation: special focus on sanitation. New York, NY and Geneva, Switzerland: WHO & UNICEF, 2008.

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
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. [Online]. 2007 [accessed 20 June 2009]. http://data.unaids.org/pub/Report/2008/JC1521_stigmatisation_en.pdf.

2. Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociology of Health & Illness 2005; 27(4): pp. 468-489.

3. Courwright AM. Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics 2009; 23(2): pp. 90–96.

4. Cameron E. Witness to AIDS. Cape Town: Tafelberg Publishers Limited; 2005.

5. World Health Organization. Mental Health: Disorders Management. [Online]. 2009 [accessed: 21 June 2009]. www.who.int/mental_health/management/en/.

6. Barney LJ, Griffiths KM, Christensen H, Jorm AF. Exploring the nature of stigmatising beliefs about depression and help-seeking: Implications for reducing stigma. BMC Public Health 2009; 9(61).

7. Flanagan EH, Miller R, Davidson L. ‘‘Unfortunately, We Treat the Chart:’’ Sources of Stigma in Mental Health Settings. The Psychiatric Quarterly 2009; 80: pp. 55-64.

8. Corrigan P. How Stigma Interferes with Mental Health Care. American Psychologist 2004; 59(7): pp. 614-625.

9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic. [Online]. 2008 [accessed 20 June 2009]. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

10. Bos AER, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: The importance of theory- and evidence-based interventions. Psychology, Health & Medicine 2008; 13(4): pp. 450-460.

11. Paxton S. The paradox of public HIV disclosure. AIDS Care 2002; 14(4): pp. 559-567.

12. Spagnolo AB, Murphy AA, Librera LA. Reducing Stigma by Meeting and Learning from People with Mental Illness. Psychiatric Rehabilitation Journal 2008; 31(3): pp. 186-193.

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.

What are the main threats to women’s health in developing countries?

Introduction

Women’s health has rarely been at the forefront of international developmental programs and national health planning policies. The focus on women’s health in developing countries has been influenced largely by other concerns such as achieving specific targets like family planning and child survival. (1) Developing countries bear a large burden of a vast plethora of diseases affecting women and it is hard to imagine how serious reforms and improvements could occur without colossal investment in the health care sector. Nevertheless, it is possible that the responsibility for women’s health be assumed by certain communities and groups in such a way that prioritizes women’s own perceptions and primary needs. (2, 3) Among the main threats to women’s health living in developing countries include gynaecological and obstetrical problems, nutrition, domestic violence etc as is shown in the schematic diagram below.

Adapted from (3)

Main Threats

Gynaecological and obstetrical problems

Women in developing countries are faced by a number of diverse gynaecological and obstetrical problems including sexual health issues, abortion, cancer and complications related to pregnancy such as obstetric trauma (eg, obstructed labor, post-partum hemorrhage, vesico-vaginal fistulae, perineal lacerations). The ubiquity of sexually transmitted infections (STIs) including HIV is alarming in developing countries particularly Sub-Saharan Africa whereby 40-50% of women attending antenatal care clinics are HIV positive. Moreover, studies carried out in Kisumu, Kenya and Zambia highlighted significantly high HIV prevalence rates of 30-73% in women of reproductive age. Thus STIs remain a leading cause of morbidity with far reaching biological, social and economic consequences especially among women.

Cervical cancer

Cervical cancer is the commonest cancer among women in developing countries. Annual global estimates in the year 2000 were for 470,600 new cases and 233,000 deaths from cervical cancer yearly. Human Papilloma Virus (HPV) is prevalent in 99.7% of cervical cancer cases with subtype HPV 16 and HPV 18 present in more than 80% of invasive cervical cancers. (2) India, Bangladesh, Nepal and Sri Lanka together contribute around one third of the global cervical cancer burden as shown in the table below. (4)

Maternal deaths and cervical cancer burden in South Asian countries

Adapted from (4)

^a Estimated in the year 2000 (approximately).
^b Estimated in the year 2002 (approximately).

Complications of Pregnancy, Abortion and Female Genital Mutilation

Complications of pregnancy and childbirth have been recognized as being the leading cause of death among women of reproductive age. Of over 500,000 maternal deaths that occur annually, 95% take place in resource poor countries of Africa and Asia. (5) Unwanted pregnancy poses great threat to women’s health. Despite under-reporting around 36-53 million women unwanted pregnancy are terminated by induced abortion annually throughout the world. Unsafe termination of pregnancy may result in death or morbidities such as infection, haemorhage, uterine injury and toxic effects of interventions. Furthermore, unsafe abortion has other consequences, namely economic costs to health systems and families, stigmatization, and psychosocial effects on women. Deaths related to unsafe abortion symbolizes about ¼ to 1/3 of the estimated 500,000 maternal deaths that occur worldwide annually, the vast majority in developing countries. (2, 6) Furthermore, female genital mutilation practiced in some Asian and African countries can cause extreme injury and extensive tearing during childbirth because the scarred vaginal opening cannot stretch to allow passage of the fetal head. Every year nearly 2 million girls aged 4-12 years old are mutilated mainly in Egypt, Ethiopia, Kenya, Nigeria and Somalia so as to preserve their virginity and ensure marriage thereafter. (9)

The 585,000 women who die worldwide in pregnancy annually leave behind them at least 1 million motherless children. The death of a mother is almost twice as dangerous for her surviving children as the death of a father. In developing countries, women are the major breadwinners and are responsible for the 60-80% of all food production in Africa. Hence, for the sound development of children and a family, gynaecological and obstetrical practices must be improved. (9)

Nutrition

In developing countries, poor nutrition among women is a conspicuous cause of low birth weight (LBW). Studies show that maternal nutrition factors both before and during pregnancy account for greater than 50% of cases of LBW in many developing nations. (7).Several factors including poverty, women’s status, cultural beliefs and practices may act as barriers to the birth of a normal weight baby. Poverty acts to limit access to care and the choice and amount of foods available to pregnant women. Similarly, anaemia, which is commonly due to iron deficiency is a problem in the same areas where LBW is a concern. Studies revealed that rates of anaemia have decreased neither among pregnant nor non-pregnant women. (8) Most women in developing countries suffer from malnutrition during pregnancy and lactation. In certain poor countries, men and boys are preferentially fed before women and girls. About a third of women in Sub-Saharan Africa have an inadequate daily calorie intake. (9)

Healthy maternal nutrition is considered as the lifeblood for the healthy and reproductive performance of women, survival and fostering of their children. The magnitude of female malnutrition and the subsequent social, economic, health, developmental repercussions of poor, limited prenatal nutrition of women and children provide an impetus for systemic, robust and rapid actions. Likewise, because of the reproductive and long-term effects of childhood malnutrition on adult physical and intellectual productivity as well as impact on women’s health and nutrition on child survival, securing nutrition of women remains a socially and economically prominent objective to be achieved by developing countries. (12)

Violence Against Women and Rape

Domestic Violence is defined by the World Health Organization as “the range of sexually, psychologically and physically coercive acts used against adult and adolescent women by current or former male intimate partners.” (10)It is a serious problem around the globe experienced mostly by women. Violence within intimate relationships might be affected by personal, cultural, religious and psychological factors. Furthermore past studies have shown a nexus between partner violence and social factors like poverty and weak community sanctions against partner violence. Likewise, studies from developing countries and Muslim population found that low education and socioeconomic status and being a Muslim living in a nuclear family, low self-esteem and being with a partner who abuses alcohol and other substances to be linked with domestic violence. Moreover, international research suggests that women with disabilities suffer significantly more from sexual violence compared to other women. In general women with disabilities are ‘assaulted, raped and abused at a rate of at least two times greater than women without. (11)

The risk of domestic violence is higher among women infected with HIV or who perceive themselves to be at high risk of acquiring HIV infection from their spouses because they may be unwilling to have sexual relations with their partners. The latter may thus retaliate with physical violence. Risk factors for domestic violence and HIV infection intersect and overlap. Hence there is a need to raise awareness of the propinquity of domestic violence to HIV infection. (10)

Conclusion

Increased female autonomy has been shown to confer an aura of hope to policies like higher child survival rates and better allocation of resources in favour of children in the household. (13) Furthermore, screening programs, education and training must be made accessible to women because they play pivotal roles in reducing the number of unwanted pregnancies and increasing awareness to women’s health. Finally, the arsenal of existing laws concerning women need to be strengthened so as to protect them against domestic violence and any other forms of violence.

Kevin Mohee is a third year medical student at Leeds University in the UK
um06krm@leeds.ac.uk

References

1. Mirta Roses Periago,* Ricardo Fescina,* and Pilar Ramón-Pardo. Steps for Preventing Infectious Diseases in Women. Conference Report. Pan American Health Organization, Regional Office of the World Health Organization, Washington, DC, USA

2. Javed H. Rizvi, Nadeem F. Zuberi. Women’s health in developing countries. Best Practice & Research Clinical Obstetrics & Gynaecology, Volume 20, Issue 6, December 2006, Pages 907-922

3. Narjis Rizvi, Sania Nishtar . Pakistan’s health policy: Appropriateness and relevance to women’s health needs.Health Policy, Volume 88, Issues 2-3, December 2008, Pages 269-281

4. Rengaswamy Sankaranarayanan, Neerja Bhatla, Patti E. Gravitt, Partha Basu, Pulikattil O. Esmy, K.S. Ashrafunnessa, Yasantha Ariyaratne, Aarati Shah, Bhagwan M. Nene. Human Papillomavirus Infection and Cervical Cancer Prevention in India, Bangladesh, Sri Lanka and Nepal Vaccine, Volume 26, Supplement 12, 19 August 2008, Pages M43-M52

5. Tamunosa Okiwelu, Julia Hussein, Sam Adjei, Daniel Arhinful, Margaret Armar-Klemesu . Safe motherhood in Ghana: Still on the agenda? Health Policy, Volume 84, Issues 2-3, December 2007, Pages 359-367

6. Gilda Sedgh, Stanley Henshaw, Susheela Singh, Elisabeth Åhman, Iqbal H Shah. Induced abortion: estimated rates and trends worldwide. The Lancet, Volume 370, Issue 9595, 13 October 2007-19 October 2007, Pages 1338-1345

7. M.F. Fathalla. Health and being a mother in the twenty-first century. International Journal of Gynecology & Obstetrics, Volume 98, Issue 3, September 2007, Pages 195-199

8. Usha Ramakrishnan. Nutrition and low birth weight: from research to practice. SPECIAL ARTICLES. American Journal of Clinical Nutrition, Vol. 79, No. 1, 17-21, January 2004

9. John O’Loughlin. Safe motherhood: impossible dream or achievable reality? MJA 1997; 167: 622-625

10. Dan K Kaye. Gender inequality and domestic violence: implications for human immunodeficiency virus (HIV) prevention. Afr Health Sci. 2004 April; 4(1): 67–70.

11. Farooq Naeem, Muhammad Irfan, Qaiser A. Zaidi, David Kingdon, Muhammad Ayub. Angry Wives, Abusive Husbands: Relationship Between Domestic Violence and Psychosocial Variables. Women’s Health Issues, Volume 18, Issue 6, November-December 2008, Pages 453-462

12. Jose O Mora and Penelope S Nestel . Improving prenatal nutrition in developing countries: strategies, prospects, and challenges. American Journal of Clinical Nutrition, Vol. 71, No. 5, 1353S-1363s, May 2000

13. Siwan Anderson, Mukesh Eswaran . What determines female autonomy? Evidence from Bangladesh. Journal of Development Economics, In Press, Corrected Proof, Available online 6 November 2008

A child dressed in dirty rags is crying. Her young mother adjusts her pallu over her head, as they tentatively enter the clinic. After waiting for hours among the ill, they are finally seen. The doctor gently pinches the child’s skin and looks into her sunken eyes. She quickly makes the diagnosis – another clear cut case of dehydration due to diarrhea. The doctor then patiently explains the importance of feeding the child an oral rehydration solution. But while she writes out another prescription for antibiotics, the doctor can’t help but feel some frustration. This child will come back again and again with the same illness, because this family simply does not have access to clean drinking water.

Prevention would seem to be the ultimate solution to the scenario. However, the practice of medicine has traditionally followed a strictly biomedical model, focusing on the diagnosis and treatment of disease. Accordingly, medical centers that are viewed as being particularly cutting edge and modern are ones that provide super-specialized, but ultimately fragmented care. While such centers have an important role in researching and treating rare and unusual diseases, what about the types of diseases that are a consequence of a lack of education, systemic inequities based on gender and caste, and poverty? How effective are modern cures if they do not address the social, economic, and developmental issues that are as intrinsic to the pathogenesis of disease as pathogen entry, epithelial attachment, and colonization? Drs. Mabelle and Rajanikant Arole asked these same questions when they founded the Comprehensive Rural Health Project (CRHP) in Jamkhed, India in 1970. They described their first experiences in treating the rural poor:

We were finding that our medicines, however modern, did not provide a permanent cure for common illnesses….We began to see how really shortsighted we had been. We were too busy running an ambulance service at the bottom of a cliff rather than preventing accidents by putting a fence at the top. (1)

In order to truly treat the indigent populations of rural Jamkhed and the surrounding communities, they had to address the root causes of disease: lack of food, unsafe drinking water, and bad sanitation. And in order to reach the neediest, they realized they would have to simultaneously address the social issues of gender and caste.

The CRHP complex

Breaking through deep rooted social constructions is a difficult task, but not insurmountable. The traditional model of medicine is very hierarchical, with nurses and auxiliary and ancillary staff playing strict roles, with doctors at the ‘top’, dictating the management of the case at hand. But in order to make real social change in the communities around Jamkhed, the Aroles decided it would have to come from within. As Dr. Shobha Arole, the Aroles’ daughter and current associate director of CRHP, noted, “Empowerment is the basis of our work.” They facilitated the construction of Farmers’ clubs and Mahila Vikas Mandals (Women’s clubs), which met regularly to discuss the interests and concerns of villagers. The villagers were able to focus on the health of the community only after addressing fundamental issues such as access to food, water, and shelter.

With CRHP, the Aroles introduced innovative ideas for the delivery of care to marginalized populations. But perhaps the most ground-breaking is the concept of the Village Health Worker (VHW). The VHW is a member of the village she served, and is selected by its people. She serves as a conduit of communicating what the community’s specific needs are to CRHP, and as a trusted person who acts on the behalf of CRHP to introduce health interventions such as safe deliveries for pregnant women, nutrition education, and the identification of people suffering from diseases such as tuberculosis and leprosy, to be brought to the hospital for treatment. “The women had first hand experience of surviving in an adverse sociocultural environment. They taught us how village people perceive disease in the context of their poverty and how they respond to various situations.” (1) With their insight, VHWs are able to address superstitions such as villagers treating cobra bites with a trip to the temple and reroute them instead to the hospital; and adapt health care messages using language, imagery and metaphors so they would be relevant to villagers.

Village Health Workers Jijbai and Sonabai

VHWs do their outreach work by spending an hour or two each day visiting different families in their villages. By reaching out to even the poorest families, VHWs would ensure that even the most deprived would have access to preventative services and medical care.

Indeed, many of the VHWs themselves were illiterate before their CRHP training or come from ‘ow caste’ and Dalit (’untouchable’) backgrounds. Salubai, a veteran village health worker, was thirty-five years old when she was chosen by her fellow villagers to be the VWH for her village, Ranjun. Because she is a Dalit, she initially experienced discrimination as she tried to visit the higher caste homes in her village. “When I first started, people would shut the door in my face because I was not educated and of low caste.” But soon, word spread about her effective services. “My first delivery was my cousin’s child. It was a safe, successful delivery and I was very happy with the experience.” Eventually, high caste families started requesting her to deliver their children. Since then, Salubai has conducted over 250 deliveries and boasts a 0% mortality rate for both the newborns and the women she has delivered.

It typically takes about six to eight months for a VHW to establish her credibility within the villages (1). During this time, she attends training sessions at the main CRHP facility and acts as an apprentice to an older, more established VHW. While the VHW acts as a representative of the community, it is also important for the VHW to view herself as a part of the health care team in order to overcome her own disempowerment she’s experienced from being a woman or from a low caste background. The role of the VHW is further reinforced through regular visits from the mobile health team, which typically featured a doctor, nurse, social worker, and other members that conduct medical and social services. “The visible support of deliberately training the VHWs in front of the community legitimised their role in the village. A doctor’s reinforcement of her treatment as the best treatment increased her confidence.” (1)

Because the VHWs were so effective with the knowledge they had gained through their training at CRHP, they gained additional responsibilities such as treating minor illnesses. As reliable providers of medical care, VHWs often found themselves respected members of their communities, despite the structural inequities that many women in rural villages face. Lalanbai, a Dalit from Pimpalgaon, was married at ten years old, illiterate, and received only leftover food tossed to her for dawn to dusk labor (1). “I had thought of myself as nobody. I had always been made to feel less than an animal….I had no self respect because people addressed me with contempt.” (1) After Lalanbai was selected by her village to become a VHW, she flourished in the supportive environment that CRHP training provided her. With her health care training, she was able to effectively intervene in medical issues that were important to the people of her village, particularly safe deliveries and neonatal care. Like any other primary care provider who is intimately involved in the lives around her, she went from being an ‘untouchable’ to an important person in the village. Her fellow villagers, who once ostracized her, then wanted her to become the mayor of the village (1). As Lalanbai describes her own personal revolution, “As I have changed, I have changed the world around me, even this backward village of Pimpalgaon, and that is the best reward for me.” (1)

Empowered by knowledge and self-esteem, village health workers have been able to make a difference not just in their own lives, but in others’ as well. Their role as health care providers allows them intimate access into their neighbors’ lives, providing hope for those who have none. Social issues are often entangled with medical problems, and as members of the same community, VHWs aim to address both. Ratna, a young woman from rural Maharshtra, has a particularly moving story.

She was 16 years old when she married and moved with her husband from rural Maharashtra to a suburb of Mumbai. She felt lucky because was the youngest of four girls and had married someone who did not want a dowry. Within six months she discovered she was pregnant. But not long after that, she found out her husband had AIDS, and that she and her baby had contracted the virus as well. Soon, her neighbors found out. The family was cast out by their community in suburban Mumbai, and they were forced to return to Ratna’s mother-in-law’s house in rural Maharashtra. Life was not much better there either. As Ratna explains, “My mother-in-law would not allow me to cook or touch the drinking water out because they were afraid of catching the illness.” Even when she went to collect water from the public well, other people in the village would wash the area after she used it.

After two months, Ratna’s husband died from AIDS. “My in-laws told me, ‘We have no relations with you,’” and Ratna was forced to take her child and move back in with her mother. There too, her experience was steeped with the stigma of AIDS and ignorance about how it is transmitted. “My mother was afraid that it would spread to the two small boys living in the household. I was not allowed to use the common bathroom or cook in the house.” Determined to earn a living to support her child, she tried to find work as a farm laborer, but there too she experienced discrimination as a result of ignorance, and had difficulty holding a steady job. “Whenever I would find a job, after a few days my co-workers would find out I have AIDS and refuse to work with me. I would be fired the next day.”

At a new job, Ratna was told she couldn’t bring her baby to work. Ostracized by her family and with no money, Ratna was forced to leave the baby alone at home one day. She then came home after work and found her baby dead. Having lost everything with her child dead, her husband dead, and cut off by seemingly everyone around her, she became completely hopeless. She decided that she couldn’t go on living, and took poison in a suicide attempt.

Fortunately, neighbors found her in time, and a CRHP village health worker came to see her. “When she came to see me, I was very weak. She knew what had happened – that I had taken poison to end my life. She was so caring and reassuring; I didn’t want to tell her I had AIDS because I was afraid she would abandon me.” The VHW reassured her that she would continue to support her, and took Ratna to Dr. Arole for treatment. At CRHP she was nursed back to health, but the question still remained regarding her status in society. Physically she had gotten better, but she still suffered from mental and emotional anguish. “They asked me what I did for a living. I told them, ‘I don’t do anything because I can’t get a steady job.’ I was in despair.”

Dr. Arole offered Ratna a job on the CRHP Khadkat farm, the site of CRHP’s Mabelle Memorial Training and Rehabilitation Center. There she learned skills such as operating tractors, and producing jams and jellies. More than that, by including her in social functions and doing things such as simply eating with her, the stigma that surrounded Ratna as a person living with AIDS soon dissipated. Once the other villagers saw Dr. Arole, a highly respected man of the community, including Ratna in social activities, they realized that they had no reason to exclude her from their lives.

Ratna not only survived, but has excelled at her job on the farm. She smiles as she tells us she was promoted to the manager of the farm two years ago, and continues to enjoy that position. She is now an enterprising, vivacious woman who sees hope in her life.

Ratna, giving us a tour of the farm she now works at

Using VHWs to reach out to stigmatized communities has been an effective method to dispel myths and misinformation within villages. By acting as couriers to remote sites, they educate their neighbors and improve access to care. Indeed, a number of health care measures in the villages reached by CRHP have demonstrated staggering results. Indicators such as infant mortality rate have dropped drastically since the inception of CRHP, from 176 deaths per 1000 births down to less than 50 in 1992 (1). Prenatal care and immunizations are now close to approaching universal coverage. In 2005 CRHP reported that in the villages they cover, 99% of children under five were receiving DPT and polio vaccines, while 97% of pregnant women received prenatal care. In contrast, country-wide statistics for India in 2006 indicated only 55.3% of children were immunized, and 50.7% of pregnant women received prenatal care (2).

Monitoring the weight of babies. The babies usually don’t enjoy being weighed, but monitoring their growth is a good way to screen for malnutrition, and an opportunity to give nutritional advice to the mother

Because preventable deaths and communicable diseases have been so well managed in the villages reached by CRHP, their model has received national and international attention. The government of India has recognized the effectiveness of using village health workers to reach out to rural and marginalized communities, and in 2005 started a program called Accredited Social Health Activists (ASHA) based on this concept. The goals of this program echo many of CRHP’s accomplishments, including a reduction in infant and maternal mortality rate, prevention and control of locally endemic communicable diseases, and population stabilization. As a ‘Health Activist’ the ASHA would address the social determinants of health – her primary job would be to dismantle harmful superstitions, encourage parity in the treatment of female and male children, and direct sick individuals to medical care.

Because neonatal/maternal mortality and communicable diseases have been so well addressed, now the VHWs are learning how to screen for diabetes and hypertension. Here Jijbai and Sonabai demonstrate to other VHWs how to check for glucosuria

In theory, it seems simple enough to take one successful program, and apply it to the rest of the country. And while superficially, the CRHP’s village health worker program and the ASHA program appear quite similar; in practice they are quite different. In a conversation with Dr. Arole, he pointed out the social standing of the women selected as the village ASHA is far more important than the degree of her formal education, the latter being a point emphasized with the government program. “It’s important the ASHA be someone that has the time to visit the people in her community. Women who are old enough to have a daughter-in-law helping out at home have time to fulfill the responsibilities of an ASHA. Younger women have more household responsibilities. They also traditionally move to their husband’s village – they would not have the social standing, nor the familiarity that an older, more established woman would have in the community.” Moreover, he also feels the training of ASHA should stress practical information applicable to communities, as opposed to the emphasis on anatomy and physiology in the current curriculum.

A village health worker taking a young pregnant woman’s blood pressure

The ASHA program is not unlike the Voluntary Health Guide program of 1977, an older government scheme that attempted to adapt the CRHP model, and it’s unclear what lessons have been learned from that failed program and what changes have been made. The reality is that a copy-and-paste approach to instituting programs in a country as culturally, religiously, and developmentally diverse as India may produce problems. In the communities served by CRHP, the villagers had organized into pro-active Farmers’ clubs and Women’s clubs, through which they voiced the needs of their community in a collective manner, and then worked together to solve them. In this way, they were empowered to choose the most appropriate person as a village health worker. However, in communities in which the people are not organized or empowered, the selection of the ASHA has become much more political, despite the selection guidelines the government of India has put out. Similarly, the status of women in certain parts of India is much more marginalized than others, and it would not be appropriate to recommend a woman going house to house in these circumstances. “Each community is very different,” says Dr. Arole. “Such a program should first be done on a pilot basis.” Under these conditions, perhaps the selection criteria will be better scrutinized, and the government would be able to play a role in removing political interference.

Today, CRHP cares for over 300 villages, a total population of about 500,000. Some would argue that the key to CRHP’s success is that they worked with the communities around Jamkhed as partners. Traditionally, only highly trained health care professionals have been entrusted to disseminate public health information and provide medical care. Hierarchy prevailed, and medicine was cloaked in a mystique that was only accessible to the wealthy and educated. Now, as medicine is beginning to move towards a patient-centered approach which recognizes the unique needs of each patient, programs instituted with good intentions should also recognize the differences in each community in order to serve them most effectively. Likewise, the paradigm is shifting to accommodate the growing need for primary care in almost every setting. It is increasingly recognized that a ‘teamwork model’ – one that respects the contribution of each member, and acknowledging the communities’ needs as important, rather than experts dictating what’s best – may be a better approach to improve access to care. By working with local people in villages, CRHP was able to identify and address the most pressing needs of the communities they served. Trust is built, aided by village health workers, and only then effective health interventions can be made. Drs. Mabelle and Rajanikant Arole recognized and addressed the link between social issues and health, thus revolutionizing the communities they served. As public health luminaries Daniel Taylor and Carl Taylor succinctly put it in their book, Just and Lasting Change, “[T]he key to building better lives is not technical breakthroughs but changing behavior at the community level.” (3)

Himali Weerahandi is a 4th year medical student at Temple University School of Medicine in Philadelphia, USA

weerahandi@gmail.com

References

(1) Arole, Mabelle. Arole, Rajanikant. Jamkhed: A Comprehensive Rural Health Project. 1994. Comprehensive Rural Health Project.

(2) Arole, Rajanikant. Arole, Shobha. Comprehensive Rural Health Project: Jamkhed India: Annual Report 2007-2008.

(3)Taylor, Daniel. Taylor, Carl. Just and Lasting Change. 2002. The Johns Hopkins University Press.

Please visit www.jamkhed.org for more information.

I recently viewed the video “Pediatric Medicines – Prescribing Drugs ‘Off-Label’” reported by R. Frederick in Science [1]. The video highlights the issue surrounding off-label prescribing of medications to pediatric patients and summarizes the history and need for further inquiry. Briefly, the lack of pediatric-friendly formulations places nearly 40% of the world’s population at increased risk for non-compliance, decreased access to new medicines, suboptimal dosing, and avoidable side effects [2]. Although this issue has been a topic of hot debate for over a decade and incentives were put in place with the FDA Modernization Act of 1997, we are less than four years away from the expiration of Acts enacted by the US Congress that require pediatric clinical trials (namely, the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA)) [3]. One of the provisions that permits waiver of the PREA regulations is if pediatric studies are deemed impossible or highly impracticable. We must make strides in improving our ability conduct pediatric clinical trials. One technology may help in this respect.

The only innovative change highlighted in the video is virtual modeling of medications in pediatric populations being carried out by Professor Geoff Tucker of Simcyp (UK), a research-based company providing predictive pharmacokinetic services. The Simcyp Paediatric Simulator permits physiologically-based pharmacokinetic modeling and the prediction of drug absorption, distribution, metabolism and excretion based on either in vitro findings or adult in vivo data. As reported recently by Simcyp, the FDA has renewed its contract with Simcyp and has increased the number of various licenses to use their simulator [4]. An initiative by Pfizer is also yielding strong results, as reported in the British Journal of Clinical Pharmacology, identifying drug-drug interactions as shown by a Simcyp application [5]. Familiarizing the pediatric community in the US with Simcyp will be an important next step to help in bringing research together to gather results for the medical community.

In my opinion, the traditional reluctance to enroll children in clinical trials has had the effect of increasing, not decreasing, their vulnerability as a special population. Overall, I commend the European community for taking measures to establish definitions that can be used in the healthcare community [6]. It is imperative that the American medical community join in these efforts as this is a worldwide issue. It seems everyone is aware of the issue and being able to define the parameters will bring the healthcare community together.

It is true that research done on children is ethically questionable but the medical community and critics should be aware that innovative non-invasive measures are being used worldwide to help make medications safer for children. The great myths in pediatrics – children are little adults and children can be prescribed a lower dose of the same drug – have been widely dispelled [7]. But, we must now measure pharmacokinetic, pharmacodynamic, and response effects across different age ranges and establish the true differences of drug effects on adult and pediatric populations. Perhaps virtual models can place us one step closer to this goal.

Shaheen Lakhan is currently Executive Director of the Global Neuroscience Initiative Foundation based in Los Angeles, California.

slakhan@gnif.org

References

1. Frederick R. Video: pediatric medicines–prescribing drugs “off-label”. Science. 2008 322(5899):209.

2. Milne CP, Bruss JB. The economics of pediatric formulation development for off-patent drugs. Clin Ther. 2008;30(11): 2133-45.

3. Law Strengthens FDA. 2007; http://www.fda.gov/oc/initiatives/advance/fdaaa.html

4. US FDA renew contract with Simcyp. 2008; http://www.simcyp.com/News/20081008_FDA+renews.htm

5. Youdim KA et al. Application of CYP3A4 in vitro data to predict clinical drug-drug interactions; predictions of compounds as objects of interaction. Br J Clin Pharmacol 2008;65(5):680-692.

6. Neubert A et al. Defining off-label and unlicensed use of medicines for children: Results of a Delphi survey. Pharmacol Res. 2008; 58(5-6):316-22.

7. Lakhan SE, Hagger-Johnson GE. The impact of prescribed psychotropics on youth. Clin Pract Epidemol Ment Health. 2007;3:21.

Vishal Raman explains the situation of Third World child malnutrition and discusses how efforts to combat it still have a long way to go.

The World Health Organisation (WHO) regards hunger as the gravest single threat to the world’s public health. This should come as no surprise to those who have read the 2008 Lancet Series on maternal and child undernutrition, which estimates that 3.5 million children under 5 years are dying annually due to hunger related causes (1-5). It is a sad fact that although these deaths are largely preventable, nutrition still remains a severely neglected issue on the global health agenda. Norman Borlaug once described the existence of a “forgotten world – where people live in poverty, with hunger as a constant companion and fear of famine as a continual menace.” At this defining moment in the fight for social justice these children must not be forgotten and this issue cannot be ignored.

It is thought that 178 million children under 5 years are stunted (see box) and 80% of them live in just 20 countries predominantly located in south-central Asia and sub-Saharan Africa (1). India alone is home to 61 million, which is 51% of all Indian children under 5 years. Globally, 112 million children are underweight and 55 million are wasted, of whom 19 million suffer from severe acute malnutrition (SAM). The sheer magnitude of this crisis must not be underestimated. Maternal and child undernutrition is the underlying cause of 35% of the disease burden in children of this age group and 11% of the total global disability adjusted life years (DALYs) (1). It is now clear that a critical window exists in a child’s life, from conception to 2 years of age, where inadequate nutrition causes irreparable damage and leads to serious long-term consequences (2). Stunting and severe wasting in the first two years of life have been shown to permanently impair an individual’s growth and cognitive development. They are associated with reduced educational achievements, increased risk of chronic disease and diminished economic potential in later life (2). In fact, an excellent predictor of future capital is a child’s height-for-age at 2 years of age. Childhood undernutrition can have significant repercussions for the health of coming generations as well as the future economic capacity of these burdened nations. Therefore, all those involved in the fight against hunger should recognise that investment in this crucial period of a child’s life is vital. It will have immeasurable benefits for that individual as well as their country.

WHO Defined Indices for Assessing a Child’s Nutritional Status

Stunting – Defined as a height-for-age measurement 2 standard deviations (sd) below the reference median and it primarily reflects chronic undernutrition.

Wasting – Defined as a weight-for-height measurement 2sd below the reference median and it primarily reflects acute malnutrition.

Severe Acute Malnutrition – Defined as a weight-for-height measurement 3sd below the reference median and it is used to determine those in need of urgent life-saving therapy.

Underweight – Defined as a weight-for-age measurement 2sd below the reference median and it is a result of acute and/or chronic malnutrition

Importantly, a number of highly effective interventions exist to improve child nutritional status (3). Those with the strongest evidence base include educational campaigns that promote breastfeeding and appropriate complementary feeding, provision of foodstuffs for food-insecure populations, micronutrient supplementation and the treatment of SAM. Of the micronutrient interventions, vitamin A and zinc supplementation have had the greatest impact with universal salt iodisation also showing promise. The management of SAM has recently been revolutionised with the success of home-based treatment and ready-to-use therapeutic foods (6). This has reduced in-patient admission times and so enabled greater numbers to be treated. Universal coverage with the full package of proven therapies could reduce child mortality by one-quarter and the prevalence of stunting by one-third. Sadly, in the 20 countries with the highest burden of undernutrition a significant number of these established interventions are simply not being adequately employed (4). Only 5 of these states (Afghanistan, Bangladesh, India, Madagascar and Nigeria) report nationwide implementation of behaviour change communications to improve complementary feeding. Similarly, Indonesia and South Africa are the only countries from this group where zinc fortification has been introduced at a national level. Thus, it is essential that adequate resources be directed at specifically implementing these proven interventions in the areas where they are most required and on the scale that is necessary for substantial results to be achieved.

When designing plans to address malnutrition great emphasis should be placed on empowering local people and strengthening regional facilities. It is clear to see why when one looks at the success organisation such as Partners In Health have had by investing in community-centred care (7). They train local health workers who act as an invaluable link between health clinics and local communities by serving as counsellors, educators, treatment providers and advocates experienced in local needs. This means that the strain on both patients and local health systems is drastically reduced. Also, the health industry and economy in these areas is greatly strengthened as a result. If change is generated at this kind of grassroots level it will be powerful, meaningful and most importantly sustainable.

Unfortunately, despite the seriousness of this issue there is still an appalling shortage of international investment in improving nutritional outcomes in poor countries. It is estimated that total aid for basic nutrition in low and middle-income countries from 2000-05 was in the order of $250 to 300 million annually. In contrast, HIV/AIDS, which in fact causes the loss of less DALYs than child undernutrition does, received $2.2 billion a year in foreign aid during 2000-02 (5). A major reallocation of international donations is required; funds dedicated to dealing with paediatric malnutrition need to be greatly increased and suitably targeted.

The following words from Martin Luther King’s Nobel lecture are particularly pertinent at this time (8). “It will be a fierce struggle, but we must not be afraid to pursue the remedy no matter how formidable the task – for why should there be hunger and privation in any land, in any city, at any table when man has the resources and the scientific know-how to provide all mankind with the basic necessities of life?” World leaders and the international community as a whole must acknowledge the fierce urgency and significance of the fight against childhood hunger. This challenge has to be met with unequivocal political support and substantial financial assistance. A genuine collaborative effort between all those involved is imperative. Only then can there really be hope for every hungry child.

Vishal Raman is a 5th year medical student at Oriel College, Oxford. vishal.venkatraman@oriel.ox.ac.ukReferences

1. Black R, Allen L, Bhutta Z, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008; 371: 243–60.

2. Victora CG, Adair L, Fall C, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008; 371: 340–57.

3. Bhutta ZA, Ahmad T, Black RE, et al, for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008; 371: 417–40

4. Bryce J, Coitinho D, Darton-Hill I, et al, for the Maternal and Child Undernutrition. Maternal and child undernutrition: effective action at national level. Lancet 2008; 371: 510–26.

5. Morris SS, Cogil B, Uauy R, for the Maternal and Child Undernutrition Study Group. Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet 2008; 371: 608-21.

6. Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 2005: 81: 864–70.

7. Pih.org [homepage on the Internet]. Partners In Health. Issues We Face, Community Health Workers. Available from: http://www.pih.org/issues/delivery.html

8. Nobelprize.org [homepage on the Internet]. Martin Luther King Jr. The Nobel Peace Prize 1964, Nobel Lecture. Dec 1964. Available from: http://nobelprize.org/nobel_prizes/peace/laureates/1964/king-lecture.html

Justin Healy writes about the problems facing Asylum Seekers in Britain.

It is a peculiar feeling watching the steady stream of people walk through the door.  It is a constant procession of anxious young families, smiling elderly men, and bored young women.  Children sit quietly while their mothers talk quickly.  Some stay for a cup of tea while others hurry away.  It is a peculiar feeling hearing stories of midnight flights and dawn arrivals.

These are asylum seekers who have come to a charitable organisation for support as they tentatively trace a path through the asylum process.  The people here are often misunderstood, often maligned and often desperate. 

Almost every physician will at some point come in contact with asylum seekers as patients.  We will briefly peer into their world from the warm safety of a medical consultation.   However the evidence suggests that all too often the meeting will be an awkward one for both doctor and patient.(1)  The doctor may grow frustrated at the impenetrable language barrier while the medical history may be convoluted and peppered with vital gaps.  Meanwhile the patient may feel that the doctor didn’t understand what was wrong and that they focussed too much on the unimportant problems.  The consultation may end in weariness and dissatisfaction: the patient walks dimly back out into a world still clouded by depression; the doctor frustrated at the lack of resources and the prospect of a clinic now running fifty minutes late.

There are elements of this picture which may never be resolved.  Interpreting services are thinly stretched and there is often little opportunity in a modern medical setting to fully explore the nuances of an individual’s story.  However, a degree of understanding about the realities asylum seekers face and an insight into their own unique health problems may reduce the frustration and lead to a better standard of care. 

This article does therefore not intend to make a judgment on asylum.  To do so would be near impossible such is the political complexity surrounding the asylum system.  This article aims to ensure that flicker of time that the medical profession comes into contact with asylum seekers does not occur in an atmosphere of wary suspicion but rather one of understanding and a willingness to work together despite difficult situations.

Asylum: The Facts

Asylum seekers can be found in almost every country on Earth and the right to asylum is enshrined as a fundamental human right:

“Everyone has the right to seek and to enjoy in other countries asylum from persecution.” – Article 14, Universal Declaration of Human Rights

By the end of 2007 there were estimated to be 11.4 million refugees across the world.  There is a commonly held belief that these refugees from predominantly poorer parts of the world flock to the wealthy industrialised nations with their generous welfare systems and liberal democracies.  In fact most refugees flee to neighbouring countries which often lack the resources or capacity to adequately care for them.  For example, the UK is host to 2.5% of the world’s refugees while Pakistan is host to 17%.(2) 

Asylum seekers are often viewed with a disproportionate level of suspicion and distrust by their host country.  There are misconceptions that asylum seekers put an unfair strain on public services, get preferential benefits and are responsible for unemployment.  Research indicates that these misconceptions often arise from an imbalanced media and weak political leadership.(3)  The fact is that in many countries across the world, the life of an asylum seeker is harsh and often unfair.

In the United Kingdom for example, an asylum seeker is barred from working for an independent income during their application, rather they are obliged to live on benefits which are set at just two-thirds of what a British unemployed citizen is entitled to.  They have no choice about their accommodation and when provided it is often of a poor quality in an area with little social support.  Asylum seekers, educated professionals ones, can live in relative poverty through no fault of their own.  Indeed, a 2008 review by the Independent Asylum Commission found that the treatment of asylum seekers in the UK falls ‘seriously below the standards expected of a humane and civilised society’.(4)

Asylum seekers are a vulnerable and transient population, caught in an almost unique moment in time with their entire future hanging upon a single decision.  The often uncomfortable realities of their social situation must be taken into consideration when considering a medical management plan.

Asylum and Medical Problems

A fundamental fact to be aware of when discussing the health of asylum seekers is that they often arrive in a country in relatively good health but this health then deteriorates in the years following arrival.(5) Their health needs are predominantly related to the poverty and overcrowding that they experience once in the asylum system. 

In addition to the factors they face on arrival, asylum seekers are by definition fleeing from an unstable and dangerous situation.  They may be victims of rape, assault or torture.  They may come from nations that do not have extensive health care systems and so may have chronic conditions that have been ignored for years, or immune systems that have not be bolstered by childhood vaccinations.  Asylum seekers are therefore a population with pre-existing medical risk factors and these are exacerbated by a poor social situation.These health problems are often compounded by the fact that asylum seekers are poor users of health services.  The rules governing asylum seeker’s access to healthcare are in a well-publicised state of flux and, although asylum seekers are entitled to free primary and secondary care, they are often unsure of their rights.(7)(8)  Indeed, some asylum seekers actively avoid using health services for fear it might negatively impact upon their asylum application.(9)   Many physicians are also wary about taking on asylum seekers as patients, feeling that the investment needed in for their care is so large that the care of other patients may be compromised.(10)  Recent efforts by the government to charge failed asylum seekers for NHS care has further confused matters, leading to many physicians and asylum seekers now being unsure about what services asylum seekers are entitled to.

When managing asylum seekers, there should be a high level of suspicion for dangerous infectious diseases.  Conditions such as HIV, tuberculosis and hepatitis can immediately threaten an individual’s health and also the wider community.  It is important that the patient is fully engaged with the health system due to the nature of these communicable diseases.

Asylum and Mental Health

The refugee experience has been described as a ‘cultural bereavement’.(11)  A refugee has lost their social cornerstones: their language, attitudes, values and social structures have all been suddenly uprooted.  When this is compounded by traumatic personal stories and an immigration system that denies an independent income and permits arbitrary detention, it is perhaps not surprising that two thirds of asylum seekers experience symptoms of depression and anxiety.(12)  

The importance of an asylum seeker’s social situation in terms of developing mental illness cannot be overlooked.  Indeed, a study suggested that the social factors Iraqi refugees experienced in the UK were better predictors for the development of mental illness than the trauma in their past.(13)  A recurring theme in the psychological health of asylum seekers is that of the isolation and exclusion of families and individuals as they find themselves on the hazy margins of society.  They often lack friendship groups or know people who have similar backgrounds and experiences.  They find themselves disempowered and disenfranchised.  Fathers can no longer provide effectively for their families while often poorly educated women and children must now adapt to the values of an alien culture.  It is this social instability and loss of cultural landmarks that is commonly cited as factors for developing mental illness.(5) (6)

However, though the problems that emerge may relate to conditions of anxiety, depression or post-traumatic stress disorder, it is important to recognise the cultural differences in dealing with mental health.(14)   Mental illness can be very culturally specific, with different backgrounds having different approaches to problems.  Our own Western approach of counselling and talking-therapies may not work for patients who feel uncomfortable discussing psychological issues.  While it is important to address these problems should they arise, it should be done in a culturally sensitive way.(15)  In addition, patients may not present with mental distress in the typical way.  The evidence suggests high levels of somatisation, arising as complaints of vague physical symptoms, masking underlying psychological problems.(16)  

Aslyum: What the Doctor Should Know

The original asylum seekers were medieval fugitives, cowering in the sacred sanctuary of places of worship.  National boundaries and immigration officials have replaced the old church walls and solemn priests but the duty to guarantee protection remains the same.  The difficulty today is that it is not enough to merely escape the pursuers.  Gaining entry into the sanctuary is a long and arduous process and one that may in fact threaten the refugee’s health

A physician’s first responsibility when faced with an asylum seeker as a patient is to care for their physical and mental health.  It is important to be aware of the infectious diseases, the poorly managed chronic conditions and the assorted psychiatric problems that this population commonly experience.  Language and cultural barriers may make the conventional history taking and examination difficult, so it is important to have a high level of suspicion when it comes to these conditions.  The social problems that asylum seekers experience will only be exacerbated by ill health and it is the doctor’s role to spot the medical problem in front of them.

Some of the social stressors and psychological tensions that asylum seekers experience may not be straightforward to resolve.  It may not be possible for a doctor to ease a father’s anxiety about providing for his family or a mother’s worry about her child’s education.  These are problems which cannot be solved by a single doctor in a single consultation.  However, doctors can begin to ease to ease the burden and start to reach beyond the diagnosis and management of physical ailments.

A medical consultation can be seen as a gateway to services that can ease the psychosocial pressures on an individual.  If a physician is aware of local refugee support groups or advocacy projects they can ease the feeling of abandonment and loneliness that asylum seekers often suffer.  A physician can contact social workers if they suspect a patient is falling through cracks in the system.  Perhaps most importantly, a physician can make asylum seekers aware that the health services are there if needed.  It is in a medical consultation that a doctor can spot an individual falling away into isolation and it is in a medical consultation that a doctor can start to bring them back into society.

Simply put, it may not always be possible to truly understand or even fully support an asylum seeker who has witnessed the very worst side of mankind.  The least a physician, or indeed anyone, can do is show them the humanity they have come in search of.

Justin Healy is a 4^th year medical student at the University of Manchester, UK.

justin.t.healy@googlemail.com

 The author would like to thank Mick Sykes from REACHE in Manchester for all his help with this article.

(1) British Medical Association. Meeting the healthcare needs of refugees and asylum seekers – a survey of general practitioners. 2004. http://www.bma.org.uk/ap.nsf/Content/asylum?OpenDocument&login&Highlight=2,asylum (Accessed 15/09/08)

(2) UNHCR. 2007 Trends: Refugees, Asylum Seekers, Returnees, Internally Displaced and Stateless Persons. http://www.unhcr.org/statistics/STATISTICS/4852366f2.pdf (Accessed 20/10/08)

(3) Lewis M. Asylum: Understanding Public Attitudes. Institute for Public Policy Research Publication. 2005

(4) Independent Asylum Commission Interim Report. Fit For Purpose Yet? 2008. p2

(5) British Medical Association. Asylum Seekers: Meeting their Healthcare Needs. 2002. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFAsylumseekers/$FILE/Asylumseekers.pdf (Accessed 15/09/08)

(6) Clinical Effectiveness Group at Barts. Working with Refugee and Asylum Seekers in Primary Care

http://www.ihse.qmul.ac.uk/chs/development/ceg/guidelines/docs/Refugees%20&%20Asylum%20Seekers.pdf  (Accessed 20/10/08)

(7) Cassidy J. Free for all? BMJ 2008;337:a1111

(8) Social Care Institute for Excellence.  The Social Care Needs of Refugees and Asylum Seekers.  http://www.scie.org.uk/publications/raceequalitydiscussionpapers/redp02.asp (Accessed 20/10/08)

(9) Independent Asylum Commission Interim Report. Fit For Purpose Yet? 2008. p74

(10) British Medical Association. Meeting the healthcare needs of refugees and asylum seekers – a survey of general practitioners. 2004. http://www.bma.org.uk/ap.nsf/Content/asylum?OpenDocument&login&Highlight=2,asylum (Accessed 15/09/08)

(11) Eisenbruch M.  From post-traumatic stress disorder to cultural bereavement: diagnosis of Southeast Asian refugees. Soc Sci Med 1991;33(6):673-80.

(12) Burnett A, Peel M.  Asylum seekers and refugees in Britain: Health needs of asylum seekers and refugees.  BMJ 2001;322:544-547

(13) Gorst-Unsworth C, Goldenberg E. Psychological sequelae of torture and organised violence suffered by refugees from Iraq. Trauma-related factors compared with social factors in exile. BJPsych 1998;172: 90-94

(14) Bracken P, Giller J & Summerfield D. Psychosocial responses to war and atrocity: the limitations of current concepts, Soc Sci Med, 1995:40:1073-1082

(15) British Medical Association. Asylum Seekers: Meeting their Healthcare Needs. 2002. http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFAsylumseekers/$FILE/Asylumseekers.pdf (Accessed 15/09/08)

(16) Lin EH, Carter WB, Kleinman AM. An exploration of somatization among Asian refugees and immigrants in primary care. AmJPH 1985;75: 1080-1084

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A recent estimate suggests 9.3% of the UK population were born overseas (1). This population is heterogeneous encompassing, for example, the Windrush generation, skilled workers such as nurses and bankers, international students, asylum seekers, undocumented migrants and more recently workers from the so-called A8 nations, new members of the European Union. The focus of this article will be upon recent Black African migrants to the UK and upon HIV, which is leading to avoidable morbidity and mortality among recent migrants from Africa. Black Africans or Black African migrants will be considered as a single group because, although huge variation exists between African communities, research rarely disaggregates data by country or region of birth. The article will specifically consider the position of asylum seekers and undocumented migrants as recent and proposed changes in entitlement to NHS services seem likely to impact on efforts to meet the sexual health needs of these groups. (more…)

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A great variety of factors can influence a mother’s decision of whether to breastfeed or not. Perhaps one of the more controversial factors is the influence of powdered milk-manufacturing companies and their advertising campaigns. The company that dominates this industry is Nestlé. It controls approximately 40% of the market and is by far the main supplier of powdered milk to the developing world. (1) (more…)