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

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

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

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

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

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

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

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

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

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

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

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

References

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

Anne Aspler and Greg Queyranne take an indepth look at the atrocities currently being committed again women and girls in this troubles country

More lives have been lost in the conflict in the Democratic Republic of the Congo (DRC) than in any other conflict since World War II (1); surprisingly, it has not generated significant media attention. (2)  The little media coverage it does receive too often fails to address issues unique to women and girls, perhaps the greatest victims of the war in the Congo, to whom large-scale rapes and sexual slavery are almost exclusively reserved.  When the international community analyzes the human effects of wars, they tend to focus either on the combatants, comprised nearly entirely of men, or on the victims as a whole; seldom do they take into consideration the specific victimization of women.  

In this article, we discuss how women have been affected by the war in the Congo in a qualitatively different manner, with a focus on the extent and consequences of sexual violence.  While there is no internationally agreed upon definition of sexual violence, we will focus on one of the most extreme forms - rape - which the WHO defines as “physically forced or otherwise coerced penetration…of the vulva or anus, using a penis, other body parts or an object.” (3)  We include both a practical guideline for the acute management of rape victims, and conclude with a few suggestions for an appropriate response from the international community. 

Overview of the Conflict
Before discussing the impact of sexual violence on women, it is helpful to provide an overview of the conflict itself.  The origins date back to 1996, when Rwanda and Uganda backed a rebellion to overthrow Mobutu Sese Seko, then dictator of Zaire, as DRC was known until that time.  In 1998, Rwanda and Uganda then invaded and occupied large parts in the east and north of the Congo, (4) a country roughly the size of Western Europe. (2) The ensuing war, which Angola, Burundi, Namibia and Zimbabwe soon joined, (4) has led to the deaths of approximately 4 million people, mostly from disease and malnutrition, as insecurity has restricted access to basic healthcare services and sanitation. (5)

Much of the war has been fought over access to minerals, including gold, diamonds, and coltan, (1) a mineral essential for the high tech-industry; coltan is found in every cell phone, computer, iPod, DVD player and jet engine. (6) At least 85 multinational corporations have benefited from the war: a UN Panel of Experts has concluded that “[c]ompanies trading minerals…[are] considered to be ‘the engine of the conflict in the Democratic Republic of the Congo.’” (7)

Sexual Violence in the Conflict
Although peace accords and recent democratic elections have given the impression that the conflict is abating, violence in the eastern provinces continues. It has been determined that approximately 38,000 people die every month. (5)

Sexual violence against women and girls has been found to be “the most common form of violence” and “the most widespread form of criminality” in the war in the DRC. (5)  In a 2002 report on the subject, Human Rights Watch described sexual violence as nothing less than “a weapon of war [used] by most of the forces involved” in the conflict. (8) It is so widespread that the UN estimates that in the province of South Kivu alone, approximately 27,000 women were raped in 2006 (9) and 45,000 women in 2005, (1) though these may only be fractions of the total number in the Congo. (9)

Consequences of Sexual Violence
The consequences of sexual violence are many - not only medical, but also long-term psychological, emotional, and socioeconomic effects. (10,11,12)  Health consequences may include physical trauma to the reproductive tract, such as ecchymosis, tears, and fistulas; increased risk of sexually transmitted infections, including HIV; and increased incidence of unwanted pregnancy with subsequent unsafe abortion - which can result in pelvic inflammatory disease, infertility, and even death. (10,11) Manifestations of psychosocial problems range from post-traumatic stress disorder, depression, and attempted suicide, to more subtle signs of fear, anxiety, intrusive memories, difficulty sleeping, withdrawal, and flashbacks. (9,10)

Perhaps the most devastating consequence of rape, however, is the subsequent experience of stigma and discrimination.  Those that undergo the process of medical and psychosocial healing may return to their communities only to face total rejection from their partner, family, and community. (10) Practitioners must, unsurprisingly, be prepared to take on several roles in responding to patients who have experienced sexual violence.  The Box (below the references at the end of this article) provides basic guidelines for the acute care and management of victims. (13,14,15)

Extent of Sexual Violence
Médecins sans Frontières (MSF) has responded to the crisis in the DRC by providing treatment to victims of sexual violence in several regions affected by the conflict.  From August 2003 to January 2004, over a period of just 6 months, they reported more than 550 victims of sexual violence attending an emergency clinic in Baraka. (10) The age of victims attending the clinic ranged from 12-70 with over 75% of attendees reporting multiple aggressors, from 2 to 5 men, at a time. (10) In 2007, MSF reported treating 7,400 rape victims over four years at the Bon Marché hospital in Bunia - with an average of 50-300 women arriving every month for treatment. (16) With emergency missions in over 70 countries worldwide (17), an overwhelming majority - 75% - of rape cases dealt with by MSF are currently in eastern Congo. (18)

Discussion
Sexual violence in the conflict regions of the DRC must be confronted both on a local and international scale.  Locally, extension of health care and support services addressing both the medical and psychosocial effects of sexual violence is needed. (19) Healthcare workers may need special training in order to be prepared to respond with appropriate prophylaxis, counseling and referral for psychological and social support. (11,13) Medical intervention should be part of an integrated approach advocating for peace and security in the region and an end to sexual violence by supporting victims, documenting the extent of sexual assault, and advocating specifically for those affected by sexual violence. (11)

Beyond acute intervention at the medical level, we also have to consider the roots of the underlying conflict itself.  The links between the desire to control areas of mineral wealth and the continuing acts of sexual violence in the eastern regions calls into question how the international community should be responding to help resolve the conflict.  As poignantly expressed by journalist Jan Goodwin: “The commerce in these “blood” minerals, such as coltan, used in cell phones and laptops…drives the conflict. The brutality of the militias - the sexual slavery, transmission of HIV/AIDS through rape, cannibalism, slaughter and starvation, forced recruitment of child soldiers - has routinely been employed to secure access to mining sites or insure a supply of captive labor. “(20)

The more we ignore the victims of this brutal tragedy, and the more rapidly we consume high-electronics without demanding that components do not come from war-afflicted regions of the Congo, the less likely these horrors will end. (21)

Anne Aspler
second year medical student
 and
Greg Queyranne
first year political science student

University of Alberta
Edmonton
Alberta
Canada
aaspler@ualberta.ca and queyrann@ualberta.ca

[1] Hari, J. “A Journey into the Most Savage War in the World: My Travels in the Democratic Vacuum of Congo.” The Independent 6 May, 2006. Available from: http://johannhari.com/archive/article.php?id=863

[2] Hawkins, V. Stealth Conflicts: Africa’s World War in the DRC and International Consciousness.  Journal of Humanitarian Assistance. Jan 2004. Available from: http://www.jha.ac/articles/a126.htm

[3] World Health Organization. World Report on Violence and Health. World Health Organization. October 2002:  p. 149. Available from: http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap6.pdf

[4] Turner, T. The Congo Wars: Conflict, Myth, and Reality.  New York:  Zed Books, 2007.

[5] International Crisis Group, “Beyond Victimhood: Women’s Peacebuilding in Sudan, Congo and Uganda,” Africa Report No. 112, (28 June 2006): p.8-11.

[6] Dena Monatgue. “Stolen Goods: Coltan and Conflict in the Democratic Republic of Congo.” SAIS Review. Vol. XXII no. 1 (Winter-Spring 2002).

[7] United Nations, Security Council. “Report on the Panel of Experts on the Illegal Exploitation of Natural Resources and Other Forms of Wealth of the Democratic Republic of the Congo.” United Nations. 16 April 2001. Available from: http://www.un.org/News/dh/latest/drcongo.htm

[8] Human Rights Watch. “The War Within the War: Sexual Violence Against Women and Girls in Eastern Congo.” Human Rights Watch June, 2002: p. 1.  Available from:  http://www.hrw.org/reports/2002/drc/Congo0602.pdf

[9] Gettleman, J. “Rape Epidemic Raises Trauma of Congo War.” The New York Times. October 7, 2007. Available from: http://www.nytimes.com/2007/10/07/world/africa/07congo.html?ref=opinion

[10] Médecins Sans Frontières.  “Medical, Psychosocial, and Socioeconomic Consequences of Sexual Violence in Eastern DRC.”  Médecins sans Frontières. 2004. Available from:  http://www.msf.org/source/countries/africa/drc/2004/drcreport-nojoy.pdf

[11] Shanks, L. and Schull, MJ.  “Rape in war: the humanitarian response.” Canadian Medical Association Journal. 2000 October 31; 163 (9): p. 1152-1156.

[12] World Health Organization. Violence against women. World Health Organization. July 1997. Available from: http://www.who.int/gender/violence/v7.pdf

[13] Mein, JK, Palmer, CM, Shand, MC, Templeton, DJ, Parekh, V, Mobbs, M, Haig, K, Huffam, SE, and Young,L.  Management of acute adult sexual assault. Medical Journal of Australia. 2003 178 (5): p. 226-230.

[14] Sommers, MS. Defining patterns of genital injury from sexual assault: a review. Trauma Violence Abuse. July 2007 8 (3): p. 270-80.

[15] Brode, S. and Schofield, L.  Emergency Medicine. Toronto Notes: Comprehensive Medical Reference. 23^rd ed. Toronto: University of Toronto. 2007.  p. 34-35

[16]  Médecins Sans Frontières.  Ituri, “Civilians still the first victims”  Permanence of sexual violence and impact on military operations.  Médecins sans Frontières. 2007.   Available from: http://www.msf.org/source/countries/africa/drc/2007/Ituri_report/Ituri_report.pdf

[17] Médecins Sans Frontières. “About MSF: The MSF role in emergency medical aid.” Available from: http://www.msf.org/msfinternational/aboutmsf/

[18] McGreal, C. Hundreds of thousands of women raped for being on the wrong side. The Guardian. November 12, 2007.  Available from: http://www.guardian.co.uk/international/story/0,,2209383,00.html

[19] World Health Organization. Sexual violence: strengthening the health sector response. World Health Organization. 2007. Available from: http://www.who.int/violence_injury_prevention/violence/activities/sexual_violence/en/print.html

[20] Goodwin, J.  Silence = Rape.  The Nation.  March 8, 2004. Available from: http://www.thenation.com/doc/20040308/goodwin

[21] Queyranne, G.  “War for Minerals in the Democratic Republic of Congo.” Antidote. 2007. 4 (1): p. 6.

 Corporations are a major force shaping society and influencing health. Given their size and command over markets, corporations have great power to improve or to worsen population health. Large businesses should be leading the way in improving labour and environmental standards, yet their significant share of the market gives them the power to resist legislation upholding environmental and labour standards. (more…)

  Tuberculosis (TB) is a disease that has been a scourge of humanity from at least the time of the ancient Egyptians. The agent of human TB, Mycobacterium tuberculosis, was identified 125 years ago and effective therapy introduced over half a century ago, which many believed would eradicate the disease - at least among the wealthy. However, for multiple reasons (see bullet points below), cases have risen globally since the World Health Organisation declared it a Global Emergency in 1993. (more…)

Following his involvement in The Lancet’s current series, Nadine Cozens and Rachel Brown quiz Dr Ed Mills on the vital role of medical students in Health and Human rights. An ideal candidate for bringing this subject to light, Dr Mills’ work is focussed on the application of evidence-based decision-making to international health interventions and human rights, specifically concentrating on HIV/AIDS in developing countries. Dr Mills is based at the British Columbia Centre for Excellence in HIV/AIDS and Simon Fraser University in Vancouver, Canada.

At the beginning of our interview with Dr Mills, we realised that our knowledge of global health related human rights issues was little beyond what would be considered normal common sense. The right to health isn’t exactly a topic particularly focused on in UK medical schools, or, if it is, it is skated over in other disciplines such as ethics and medical sociology, or just assumed. So, we asked, why should medical students be interested in human rights?

(more…)

Justin Loke
5th year medical student
University of Oxford
justin.loke@green.ox.ac.uk

“Dr. A remembered [him saying], almost to comfort him, “No, they can never get the vein.” The doctor decided to place a central line. It was like placing one “for any other patient,” he said.”(1)

These words may be familiar to many students who have had to turn to their seniors when they reached that embarrassing point when they have failed to place a line or managed to take blood.  Chillingly, this is one of the most common reasons why doctors have been asked to participate in executions.  Lethal injection comprises 97% of the executions in the US since 2000 because other methods of executions are too cruel, and it is increasingly the method used by mobile execution vans in China, which leads nations in numbers of executions.  Medics have been involved with the prescription of the lethal cocktails, putting in of lines, pronunciation of death and some are involved in removal of their organs as well.  Deaths by lethal injection are sold by its proponents as a clean and fail safe method of execution.  There is increasing evidence that it is not.  Angel Diaz was recently executed in Florida.  At post mortem it was found he had 30cm long chemical burns in both antecubital fossae, which suggested that his cannulae were misplaced which would explain why it took him 34 minutes and two sets of injections to die (2).  

  (more…)

Aoife Singh
Intercalating Medical Student International Health BSc, Centre for Child & Adolescent Health, University of Bristol, Bristol BS6 6JL, UK

Throughout history, war has taken an unacceptable toll on children. They have been killed, injured, orphaned and employed as part of a country’s armed forces. However in today’s world a new and horrific phenomenon is the widespread use of child soldiers.

(more…)

Jonathan Currie, Laura Mason, Eleanor Southgate, Yolande Squire
Intercalating Medical Students International Health BSc, Centre for Child & Adolescent Health, University of Bristol, Bristol BS6 6JL, UK

The current HIV epidemic in South Africa stands as one of the most severe in the world. In 2005, 5.5 million people were living with HIV and 320 000 people died from HIV/AIDS, more than 875 lives per day ¹. Moreover, there are no signs of the epidemic reaching a plateau. Stark differences exist in the proportion of men and women affected; young women (aged 15-25 years) are approximately four times more likely to be infected than men.¹

(more…)

Lucy Morgan and Rowena Milligan
Intercalating Medical Students, International Health BSc, University of Bristol, Centre for Child and Adolescent Health, Hampton House, Bristol, BS6 6JS. lm3780@bris.ac.uk

Mr A^* fled Sudan for the UK in fear of his life after speaking out against the actions of his government. As a student, he became involved in peaceful protest and campaigned for the rights of black Africans, distributing fliers and posters. As a result government forces entered his home, arrested him and subjected him to inhumane treatment including burning, beating and being drenched with cold water. He was imprisoned for 5 days until he was released, but without the guarantee of his safety. A cousin arranged for him to be taken to the UK. He travelled for nearly three weeks on several different boats, hidden in a tiny space in freezing conditions.

(more…)

Dr. Joris Hemelaar
Final year graduate-entry medical student. Magdalen College, Oxford University. joris.hemelaar@medschool.ox.ac.uk

Last month a large-scale clinical trial of a candidate HIV vaccine started in South Africa.¹ The four-year study plans to enrol 3000 HIV-negative sexually active men and women at five sites throughout South Africa, making it the largest African HIV vaccine trial to date. In South Africa, the trial is called Phambili, which means “moving forward” in the Xhosa language.

(more…)