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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

Seriously. London, Pluto.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Panel member Sir Iain Chalmers working in the Gaza strip in the 1960s

On Thursday 13th May 2010, the Oxford Society for Medicine held an audience-driven discussion exploring obstacles to health care delivery in the occupied Palestinian territory. The panel brought together six of the leading luminaries of the medical and surgical world, and in today’s article, Omar Abdel-Mannan, president of the OSM, and Imran Mahmud report on the event, and the current status of Palestinian health.

Palestinian health has never been in a worse state…. and it continues to deteriorate. Why and how can we use our resources here in the UK to support medical professionals in the West Bank and Gaza?

On the December 27th 2008, the Israeli Defence Force (IDF) launched Operation Cast Lead, a three week military assault on Gaza. 1366 Palestinians were killed, 313 of whom were children. International doctors, Mads Gilbert and Erike Fosse, witnessed at first hand, “the most horrific war injuries in men, women and children in all ages in numbers almost too large to comprehend” [1]. White phosphorous munitions were fired upon civilian areas in Gaza, leading to widespread severe chemical burns [2].

However, what we tend to forget is that the 18 month sea and land blockade on Gaza, prior to the IDF operation and the siege which continues to this day precipitated the collapse of Gaza’s healthcare infrastructure. This is evident by the lack of basic medical equipment, such as patient trolleys, ventilators and electronic monitors for vital signs in hospitals like Al-Shifa, where Mads and Erik worked. Infant mortality and growth stunting rates in children (representing reliable indicators of health status) have either stagnated or increased between 2000-2006 [3]. A WHO survey on quality of life in 2005 found it to be lower in the occupied Palestinian territory (oPt) than all other countries studied.

Further, malnutrition, unemployment, public curfews and restrictions on movement are daily realities. The separation wall, constructed between Israel and the West Bank and declared illegal by the International Courts of Justice, continues to impede movement of Palestinians during everyday activities, and divides neighbourhoods and households [4]. Reports of patients needing life-saving operations and critical care being denied access and women giving birth at checkpoints are commonplace [5]. The need for travel permits delays access to hospitals for patients, medical students and health workers, with commuting times increasing from 30 minutes to more than 2.5 hours on a regular basis.

Wall inside Bethlehem

Chronic exposure to violence, humiliation and insecurity has bred pervasive demoralization and despair amongst Palestinians. Yet, within this context, Palestinians have cultivated a collective social resilience to occupation in the face of daily struggles [6].

This sad state of affairs for the health of Palestinians is couched within a larger context of disjointed and inadequate public health provision and healthcare infrastructure that developed over generations of different regimes. A Palestinian Ministry of Health, established after the Oslo accords in 1994 (along with the Palestinian National Authority), inherited a neglected health service from the Israeli military after decades of degradation. Current services remain inadequate for the health needs of the people, due to continuing neglect, poor management and corruption. Israeli restrictions since 1993 on the free movement of Palestinian goods and labour across borders between the West Bank and Gaza have certainly made matters much worse. The lack of any control by the Palestinian National Authority over water, land, and the environment within the oPt has made building an effective health system virtually impossible. To compound this further, the reliance on financial assistance from a multiplicity of donors, complete with their different agendas has also resulted in programme fragmentation [7].

Erez checkpoint in Gaza

So what is the solution?
Building an effective healthcare system requires command over resources, self-determination, sovereignty and free movement of people, all absent in the Palestinian territories, particularly in Gaza. This is the argument put forward by a number of world renowned academics, doctors and surgeons in a conference organized recently by myself and a number of students at Oxford University: ‘Healthcare under siege: supporting medical education in the occupied Palestinian territories’. In this gathering the expert speakers drew on their decades of personal experiences in the oPt to expose the devastating effect of crippling economic blockades and military attacks on civilian health and access to medical care, especially in Gaza. Who are these ‘experts’? Sir Iain Chalmers – A co-founder of the UK Cochrane Collaboration, Sir Terence English – the first surgeon to perform a heart transplant in the UK in 1979, Dr. Richard Horton – Editor-in-Chief of The Lancet, to name but a few.

Some of the speakers and panellists who were present at the conference: Oxford Teaching Group Dececember 2009 L to R – Dr Knight, Dr Little, Mr Dudley, Mr Nick Maynard, Dr Marfin, Mrs George, Mr Bruce George

Oxford Teaching Group April 2008 L to R – Prof Kenwright, Mr Britton, Mr Nick Dudley, Mr Maynard, Mr George

Earlier this year in February, Dr Horton and Sir Iain Chalmers visited Gaza, gaining access with the help of the charity Medical Aid for Palestinians. In his ten minute talk, Dr Horton vividly portrayed the image of a disintegrating healthcare system and a humiliated people: “Going through checkpoints is like going through cattle gate”. One of the pressing needs, as he argued, is to systematically train medical researchers and postgraduate students to build a solid foundation of medical professionals for the future. Supporting the universities, he added, is crucial to better understand the Palestinian case, to understand their needs, and to focus on supporting human rights.

Meanwhile, Prof Colin Green from University College London (and UNESCO Chair of Cryobiology with the Ukraine Academy of Science) was a key player in the extraordinary construction of a medical school from scratch based at Abu Deis in the West Bank in 1994 (with an original intake of 34 students), which today has grown to over 800 students in four campuses. As he highlights, family practice in the area is very poor and it seems that all doctors end up in the hospitals: “We need champions of primary care,” enthused Prof Green. More specialists are also need in the region, with only 1 pathologist and 2 cardiologists in the whole of the West Bank and a clear lack of Psychiatrists.

So why should we care about this region?
I personally believe, as do all the speakers, that the UK has a special responsibility towards the people of Gaza and the West Bank, due in no part to our historical ties. The Balfour declaration of 1917, which involved Britain giving away a country that didn’t belong to us, to two different national movements, was always bound to end in tears. It is thus our politicians’ responsibility today to clean up this mess, and to uphold the promise made in that same declaration that ‘nothing would be done to harm the civil and religious and human rights of existing non-Jewish communities in Palestine’.

Wall alongside road in West Bank

By discussing the UK’s wider role and moral responsibility towards the Palestinian people in Gaza and the West Bank, I am confident that we will develop and implement innovative strategies to make a positive on-the-ground difference to civilian health, access to medical services and medical education there. Oxford Brookes University’s historic decision in March to establish a scholarship programme for Gazan students (set up with the help of Dr Iain Steadman, Director of Development and one of the attendees at the conference) is one such example of the tangible difference that can be made through academia. In fact, within hours of the conference ending, a number of enthusiastic medical and humanities students from the university had already formed a student movement aiming to push through a number of short and long term proposals; including the facilitation of twining Al Quds University medical school (based in Abu Dies) to Oxford University medical school. I very much hope that this will promote elective exchanges, the sharing of ideas and teaching materials, and act as a catalyst for similar programmes at other UK medical schools.

I couldn’t help think during the conference: Why have such distinguished members of the medical elite, with hugely successful careers in their respective fields, invested so much energy in this cause – sometimes putting their jobs on the line as a result? These are people with no political, religious or cultural affiliation to the Palestinian issue, fighting for a cause that is thousands of miles from their doorstep. The simple answer is that at the end of the day, doctors and surgeons work in the business of helping people – the original Hippocratic Oath clearly states: “I will keep them (the sick) from harm and injustice”. That is undoubtedly a political statement. All medics should be championing human rights and tackling injustice across the world, wherever it rears its ugly head.

While a political solution remains distant, ordinary Palestinians in Gaza and the West Bank continue to suffer. The physical, psychological and social well-being of Gazans will remain poor, whilst the structural impediments and barriers to development remain in place. As the WHO’s Commission on Social Determinants of Health states:

“The conditions in which people live and work can help to create or destroy their health”.

The situation is grave, but it is not impossible. Within all the darkness, beacons of light across remain bright across both sides of the wall. The Director of the Institute of Community and Public Health at Birzeit University (in the West Bank) wrote in a statement to the audience at Oxford University, that all of us can individually do something to help: by supporting medical education, by visiting the region to see at first hand the challenges of daily Palestinian life, and by advocating for justice and human rights, we can make a difference.

For me the heartfelt passion and commitment of the speakers resonated with my core values as a future doctor and reminded me of why I chose medicine in the first place. Inspired by this event, I am taking the first steps on a journey that will take me to a land of challenges and resilience. I truly believe that every medic should go the occupied territories and see with their own eyes the health of ordinary, innocent people under siege.

Omar Abdel-Mannan and Imran Mahmud are both fifth year medical students at Oxford University
omar.abdel-mannan(at)medschool.ox.ac.uk

References:

1. Gilbert M, Fosse E. Inside Gaza’s Al-Shifa hospital. The Lancet 2009; 373: 200-202

2. James Hider, Sheera Frenkel. Israel admits using white phosphorous in attacks on Gaza. The Times. 24th Jan 2009

3. Rita Giacaman Rana Khatib, Luay Shabaneh, Asad Ramlawi, Belgacem Sabri, Guido Sabatinelli, Prof Marwan Khawaja, Tony Laurance. Health status and health services in the occupied Palestinian territory. The Lancet 2009. 373; 837-849

4. United Nations. Gaza Strip inter-agency humanitarian fact sheet. March 2008 http://domino.un.org/pdfs/GSHFSMar08.pdf (accessed Aug 2, 2008).

5. Hanan Abdul Rahim, Laura Wick , Samia Halileh, Sahar Hassan-Bitar, Hafedh Chekir, Graham Watt, Marwan Khawaja. Maternal and child health in the occupied Palestinian territoriy. The Lancet 2009; 272: 967-977

6. M Rutter, Resilience in the face of adversity: protective factors and resistance to psychiatric disorder, Br J Psychiatry 1985; 147: 598–611

7. Rajaie Batniji, Yoke Rabaia, Viet Nguyen–Gillham, Rita Giacaman, Eyad Sarraj, Prof Raija–Leena Punamaki, Hana Saab, Will Boyce. Health as human security in the occupied Palestinian territory. The Lancet 2009. 373; 1133-1143

Waiting area of a public sector hospital

In today’s article, Kiran Ejaz discusses the effects of gender and prejudice on healthcare delivery in Pakistan.

Lately, healthcare systems have stirred up debates across the globe.(1) Disparities in delivering healthcare are an established phenomenon. Researchers have identified racial stereotyping, age, disability, socioeconomic standing and religion contributing to such disparities. (2) These are noted to be at every level of care in terms of quality, cost and access to healthcare. (3)

Developing nations of South Asia, have extensive healthcare infrastructures on paper but they seldom deliver at the patient’s care level. Diverse ethnic groups with their unique cultures and linguistic barriers add any the existing challenges. Poverty, social injustice, gender bias, and spreading of both communicable and non-communicable diseases are issues that hinder adequate delivery of healthcare in the region; there is a need for extensive promotion and delivery of quality healthcare.(4)

In Pakistan the picture is no different from other regional countries where the arguments surrounding healthcare remain in the primary phase. We do not have a flawless system to start with ,however; males and the rich are preferred over the rest of the population, as they are the economic stabilizers. This influences the policy makers’ decisions regarding which social strata get what quality of healthcare and at how far they have to travel to get it. Gender remains one of the key factors affecting access to healthcare, and prejucdice customs in most areas of the country incline to save the male gender of all ages. (5) Nusrat S. et al identified three delays leading to high maternal mortality in the country. 88.5% of pregnant women were not aware of the quality healthcare facilities, 39.7% of women lived far away from such facilities and had to travel long distances in emergencies. Village woman are often carried on beds across fields to rough roads where after hours of waiting they would get transportation to far away healthcare facilities. The last delay identified in 49% of women, was that on reaching these facilities, if needed they were not given blood donations by their male family members. (6) It is thought amongst the uninformed and lesser educated, that blood is energy , therefore by donating it the males would lose their power to earn and head the household.

Out patient department of a public sector hospital

An example from a physician’s clinical practice is that in our trade booming city of Karachi, a patient was referred four times in two days from tertiary care hospitals due to none availability of a generic snake anti-venom. His family had to sell their family house to pay for the drug available in a private care facility, but by that time he had developed advanced stage complications that could have been easily avoided if treated in time.

A small study from Karachi’s most visited tertiary care hospital, Jinnah Postgraduate Medical Center, reported problems faced by patients. Illiteracy and poverty contributed to 80% of the problems along with 56% non-compliance to medical advice and inferiority complex leading to thinking that they are not being correctly treated in 52% of the patients.(7) Since the basic healthcare system has collapsed and medical attention is provided in tertiary care hospitals or expensive private clinics, these patients have no alternative healthcare resource.

Old age is another reflection to the healthcare delivery in Pakistan. There are ineffective and few old homes for the elders provided by non-government organizations. Most elders live with ,and are dependent on their children. Baig LA et al investigated that the majority of elders are chronic disease sufferers and there is a vacuum of social and healthcare services for them.(8) Issues of elderly and gender biases have been the state of Pakistani’s healthcare system from its existence. People from developed countries have recently voiced their concerns against their healthcare. Our generations have been living with such a healthcare system for long.

Identification of any problem should always be coupled with solutions. Some are in the process of finding solutions by planning systemic approaches to healthcare interventions such as the usage of Implantable Cardioverter Defibrillators in the socio-economically deprived. Although, it’s link to healthcare delivery disparities is still questionable.(9)

In today’s world of wars, others have found conflict to be the root cause behind social determinant of health. They advocate making pro-equity policies leading to capacity building for healthcare providers, and to eliminate barriers to access healthcare for any group. Such interventions would address factors of financial and gender blockade to ensure good health for all.(10)

Despite exploring new alternatives to improve the healthcare system, researchers faced criticism due to limitations in their designs. There have been approaches such as studying the race-country mortality disparities. Using geographic, county-level data to explore inequalities has helped policy makers, however there is a need to emphasize on social process.(11)

The common elements among all these solutions are also emphasized by Mukhopadhyay A. Cooperation and intersectoral collaboration for health can help resolve most if not all issues in providing equal healthcare to developing nations, including Pakistan.(4) Any proposed solution will be useless if it is made without keeping in view the structural factors behind disease pathology for both genders.(5) There has been improvement in the past but progress is now stagnant. Suggestions of availability and access to healthcare are important especially in rural areas. (12)

Some have moved many folds with development of academic community partnership such as the Community Physicians’ Network. They look into specific matters of the health care of African-American and other minority. (16) A similar local success story of public-private partnership seems to promote and provide women’s health to a selected pocket of women.(17)

Primary health care is vital for the better functioning of health systems. Decentralization is an opportunity to revisit our Alma Ata agenda and serve our patients.(18) Ervin PC. suggests optimizing community power by local decision making, providing education and employment to reduce poverty that is the cause behind many cases.(19) The focus of inequality of healthcare delivery in Pakistan is based on gender issues and non-availability of life saving medications in time. Solutions need to be tailored according to our cultural norms. The government officials and policy makers should advocate and implement strategies to provide immediate, free health checkups, support treatment and educate the people on health prevention and promotion.

Dr Kiran Ejaz is currently a Student Masters in Epidemiology and Biostatistics at Dow University of Health Sciences.
drkiranejaz@gmail.com

References:

1. Nathanson CA. Who owns health inequalities? Lancet. 2010 Jan 23;375(9711):274-5.

2. Dykes DC, White AA, 3rd. Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities. Clin Orthop Relat Res. 2009 Oct;467(10):2598-605.

3. Gallegos A. Retail medicine: the cure for healthcare disparities? J Healthc Manag. 2007 Jul-Aug;52(4):227-34.

4. Mukhopadhyay A. South Asia’s health promotion kaleidoscope. Promot Educ. 2007;14(4):238-43.

5. Zaidi SA. Gender perspectives and quality of care in underdeveloped countries: disease, gender and contextuality. Soc Sci Med. 1996 Sep;43(5):721-30.

6. Shah N, Hossain N, Shoaib R, Hussain A, Gillani R, Khan NH. Socio-demographic characteristics and the three delays of maternal mortality. J Coll Physicians Surg Pak. 2009 Feb;19(2):95-8.

7. Saeed A, Ibrahim H. Reasons for the problems faced by patients in government hospitals: results of a survey in a government hospital in Karachi, Pakistan. J Pak Med Assoc. 2005 Jan;55(1):45-7.

8. Baig LA, Hasan Z, Iliyas M. Are the elderly in Pakistan getting their due share in health services? Results from a survey done in the peri-urban communities of Karachi. J Pak Med Assoc. 2000 Jun;50(6):192-6.

9. McComb JM, Plummer CJ, Cunningham MW, Cunningham D. Inequity of access to implantable cardioverter defibrillator therapy in England: possible causes of geographical variation in implantation rates. Europace. 2009 Oct;11(10):1308-12.

10. Bornemisza O, Ranson MK, Poletti TM, Sondorp E. Promoting health equity in conflict-affected fragile states. Soc Sci Med. Jan;70(1):80-8.

11. Pappas G. Geographic data on health inequities: understanding policy implications. PLoS Med. 2006 Sep;3(9):e357.

12. Sathar ZA. Changes in mortality in Pakistan 1960-88. Pak Dev Rev. 1991 Winter;30(4 Pt 2):669-76.

13. Bostick N, Morin K, Benjamin R, Higginson D. Physicians’ ethical responsibilities in addressing racial and ethnic healthcare disparities. J Natl Med Assoc. 2006 Aug;98(8):1329-34.

14. Vanderbilt SK, Wynia MK, Gadon M, Alexander GC. A qualitative study of physicians’ engagement in reducing healthcare disparities. J Natl Med Assoc. 2007 Dec;99(12):1315-22.

15. Laudicella M, Cookson R, Jones AM, Rice N. Health care deprivation profiles in the measurement of inequality and inequity: an application to GP fundholding in the English NHS. J Health Econ. 2009 Dec;28(6):1048-61.

16. Ofili E, Igho-Pemu P, Lapu-Bula R, Quarshie A, Obialo C, Thomas C, et al. The Community Physicians’ Network (CPN): an academic-community partnership to eliminate healthcare disparities. Ethn Dis. 2005 Autumn;15(4 Suppl 5):S5-124-7.

17. Shaikh BT, Haran D, Hatcher J. Women’s social position and health-seeking behaviors: is the health care system accessible and responsive in Pakistan? Health Care Women Int. 2008 Sep;29(8):945-59.

18. Shaikh BT, Kadir MM, Pappas G. Thirty years of Alma Ata pledges: is devolution in Pakistan an opportunity for rekindling primary health care? J Pak Med Assoc. 2007 May;57(5):259-61.

19. Erwin PC. Poverty in America: how public health practice can make a difference. Am J Public Health. 2008 Sep;98(9):1570-2.

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

Introduction

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

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

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

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

Sequence of Traumatic Events

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

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

Mental Health Issues after KR

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

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

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

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

Getting Away with Genocide

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

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

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

Conclusion

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

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

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

References:

1. Kiljunen K. Power politics and the tragedy of Kampuchea during the seventies. Bull Concerned Asian Scholars. 1985: 1749-1764.
2. Hannum H. International law and Cambodian genocide: the sounds of silence. Hum Rights Q. 1980; 11: 82-138.
3. Kiernan B. The Pol Pot Regime: race, power and genocide in Cambodia under the Khmer Rouge, 1975-79. 2nd ed. New Haven and London: Yale University Press; 2002.
4. Shawcross, W. Sideshow, Revised Edition: Kissinger, Nixon and the destruction of Cambodia. London, England: Hogarth; 1986.
5. Mollica R, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental status of Cambodians living in the Thai-Cambodia border camps. JAMA. 1993; 270: 581-586.
6. Glass RI, Cates W Jr, Neiburg P, et al. Rapid assessment of health status and preventative- medicine needs of the newly arrived Kampuchean refugees, Sa Kaeo, Thailand. Lancet. 1990; 1: 868-872.
7. United Nations Security Council. Report of the Secretary General on Cambodia. New York, NY: United Nations Security Council; February 19, 1992.
8. Stockwell A, Whiteford H, Townsend C, Stewart D. Mental health policy development: case study of Cambodia. Australasian Psychiatry. 2005; 13: 190-194.
9. Mental Health Subcommittee Working Group. Draft Cambodian National Mental Health Plan 2003-2022. Phnom Penh: Ministry of Health, 2002.
10. Mollica R, Wyshak D, de Marneffe D, et al. Indochinese versions of Hopkins Symptoms Checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry. 1987; 144: 497-500.
11. Mollica R, Wyshak D, Lavelle J. The psychosocial impact of war, trauma and torture on Southeast Asian refugees. Am J Psychiatry. 1987; 144: 1567-1572.
12. Mollica R, Caspi-Yavin Y, Bollini P, et al. The Harvard Trauma Questionnaire: validating a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis. 1992; 180: 111-116.
13. Hu T. Financing global mental health services and the role of WHO. The Journal of Mental Health Policy and Economics. 2003; 6: 145-147.
14. Fawthrop T, Jarvis H. Getting away with Genocide? Cambodia’s long struggle against the Khmer Rouge. London, England: Pluto Press; 2004.
15. Extraordinary Chambers in the Courts of Cambodia. Phnom Penh, Cambodia: ECCC. [Accessed on: February 12, 2010]. Available from: http://www.eccc.gov.kh/.
16. Sonis J, Gibson J, Jong J, et al. Probable posttraumatic stress disorder and disability in Cambodia: associations with perceived justice desire for revenge and attitudes towards the Khmer Rouge trials. JAMA. 2009; 302(5): 527-536.
17. Friedman M. The truth and reconciliation commission in South Africa as an attempt to heal a traumatized society. In: Shalev AY, Yehuda R, McFarlane AC, eds. International Handbook of Human Response to Trauma. New York, NY: Plenum Publishers; 2000: 399-411.
18. Orth U, Maercker A. Do trial perpetrators retraumatize crime victims? J Interpers Violence. 2004; 19(2): 212-227.

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