Sir Terence English, KBE, DL, MA, BSc, FRCP, FRCS

‘All my life, I’ve taken the view that I was trained as a cardio-thoracic surgeon, and my interests lay in treating my cardiac patients in front of me. I recognized the value of Public Health, but mine was very much a clinician’s attitude’. And yet today, you will find Sir Terence English – past President of the Royal College of Surgeons, past President of the BMA, and Master of a Cambridge college – in Pakistan, helping educate women in midwifery, to address the shocking levels of infant and maternal mortality – inexorably drawn into public health and development work.

Despite his track record, Sir Terence does not seem a man obsessed with ambition. As an engineer-turned-surgeon, he once quit medical school to go prospecting in Canada – but in spite of his best efforts to break away, nine months later he found himself back in England, continuing with his medical studies.

Even his personality seems to shy away from his impressive stature, towering over the room – he sinks into the sofa, perhaps trying to hide his height, legs stuck under the coffee table in front of him. He is quiet and reserved, softly spoken, taking time with every sentence to make sure he does justice to the question asked. Almost invariably he will try to highlight the achievements of others, as though he is always a by-stander – although this is the man who carried out the first successful heart-transplant in the UK. Sir Terence is not someone who has chosen his place in history; fate has chosen him.

Since 2003, Sir Terence has been the patron of the Primary Trauma Care (PTC) Foundation, a small charity dedicated to training doctors in resource-poor settings how to cope with serious traumatic injuries. Recently returned from Iraq, he invited me into his home to talk further about PTC, and the potential for transference of knowledge and skills from the developed to the developing world.

‘In 2003, I went with a colleague, John Beavis, to North West Frontier Province in Pakistan, because he wanted to bring better trauma care there. I knew the country from my son, who had cycled through Pakistan when he was a medical student. He’d cycled up the Karakoram highway, and he’d told me that it was a fabulous country – so, when I’d finished my three years as President of the RCS, I joined a trek largely on the basis of what William had told me. It was wonderful – I love that part of the world: very remote but wonderfully grand. We walked up the Baltoro glacier all the way to the base camp of K2. This was in August 1992.

‘I had actually been to Peshawar [the capital of North West Frontier Province] two years earlier, when the RCS took a visit to Pakistan; we had a meeting first in Karachi and then some of us went to Peshawar, which is where I met the professor of surgery, Mohammad Kabir, and where he and I became good friends. So when John Beavis, in 2002-2003, said he wanted to bring better trauma care to the North West Frontier Province, I wasn’t in any way intending to get involved other than to act as a facilitator through my friendship with Kabir!

‘He proved a great help in getting us to meet the right people in Peshawar – like the governor of the Province and the Minister of Health – and put together the right people to come to the first courses which we held. And then, inevitably, I got involved, because John is a wonderful guy to work with, and we became wonderful friends. He’s got his own charity, IDEALS, and it was his idea to go to Gaza, as well.

‘The need was trauma: there are huge numbers of deaths due to trauma in developing countries. It differs from country to country – for example, in Pakistan, I think John originally wanted to go there (and particularly to the tribal areas) because a lot of children were stepping on land mines left by the Russians. So there were children losing their legs, and there were a lot of road traffic accidents – and gunshot wounds: they all carry rifles up in that part of the world, and when they get excited they fire them off and, sometimes, the bullets come back and go through people.

‘In Gaza the trauma there is largely due to the repetitive invasion by Israel into Gaza. They’ve suffered from bombs, from shelling, from tanks, from rifles, from phosphorous bombs dropped on schools.

‘So where there’s a lot of trauma, how do you deal with these people? There’s a sort of golden hour, if you like, immediately after injury. Often the local doctors may have the knowledge – because they come across trauma in surgery – but they don’t always know how to apply that knowledge in the correct order or form; and so just teaching them this can bring a lot of benefit. I’m absolutely convinced that it can be hugely useful.

‘At that time we didn’t know about PTC. Before we went to Pakistan, John and I both took the Advanced Trauma Life Support (ATLS) course at University College Hospital. There was an interesting experience: there was I, past President of the Royal College of Surgeons, John a retired orthopaedic surgeon, and both of us very frightened at the concept of failing the ATLS exam – and the faculty who were taking the course equally scared about failing us! However, we passed – and we recognized that, having done so, ATLS wasn’t going to be suitable for Pakistan.

‘And then, quite fortuitously, I met Douglas Wilkinson, who’s a consultant anesthetist and intensive care doctor in Oxford, who hails from South Africa. He considered that the ATLS, which was organized by the American College of Surgeons, was not appropriate for delivery to developing countries, because it relied too heavily on sophisticated imaging. But, he also recognized that the principles espoused by ATLS were absolutely the correct ones – the ABCDE of airways, breathing, circulation, and so on.

‘So he adapted this course for use as Primary Trauma Care; and it had been going for some years by 2003, when we went to Peshawar, and so that is what we took with the first team.

‘And it proved to be very successful. There are four medical schools in Peshawar, and through the good offices of my friend Professor Kabir, he had managed to get six of the senior people from each medical school to attend the first course; and following that we selected instructors from those 24 people. They then went back to their medical schools accompanied by a member of our team and held a course, so by the time we left there were 80 doctors trained. Then one group took a PTC course to Delhi in India, which really pleased me because this was the first example of medical collaboration between Pakistan and India for a long time.

‘So I became the Patron at the time. And since then the Pakistanis have taken the course to Iran, and PTC has now been delivered in over 40 countries worldwide. It’s still a small charity – all the instructors are volunteers. When I spoke on a Radio 4 appeal of the week on a Sunday morning I was able to point that, on average, to train a doctor in a developing country in PTC, it costs us about £50. I was hoping that this would act as a stimulus to those who might inclined to give to the charity – and indeed, we got £15,000 from the broadcast, which was a huge surprise and satisfaction.

‘Basically the course itself is designed to help doctors look after seriously injured patients in a very rather rigid way so that they don’t miss out on what really is the priority in each individual. This is delivered not just by lectures, but also demonstrations. In Gaza we had the carcass of a goat on which we could practice insertion of intercostal tubes into the chest, and we were able to remove the larynx and have a very close look at the airway.

‘Usually we have 24 to a course and about five or six instructors – initially from this country, all volunteers – so it breaks up into four groups. There are the so-called scenarios, where one of the members of that group of 6 will pretend to have been injured in a very particular way, whether he’s got a fractured femur or a tension pneumothorax or whatever. One of the members will have been excluded while this has been set up; then that member comes back, he’s told the history, and he has to get on and treat that individual – and does he do the right thing first? Does he put the oxygen mask on first straight away? Does he stabilize the neck appropriately? And the rest of the team are watching his performance all the time – he’s put under quite a lot of pressure to do things in the right way, in the right order. And after a while they love this, because they recognize how fast they’re learning; but initially they can be a bit embarrassed if they get things wrong.

‘Not all of the courses have been successful – for some in Africa, it just hasn’t been taken forward by the locals. It’s very important to get the members of the first course carefully selected, and then form a local committee that will be responsible for picking the instructors to deliver further courses. Sometimes there’s friction between different parts of the country – in Iraq, where I’ve just come back from, we’ve been making an assessment to start the courses there. When we had our preliminary meeting with doctors it was held in Baghdad, but there was strong pressure to try and deliver the first courses in different parts of the country rather than in Baghdad. We felt that what was important was to get a really well trained corps of instructors first and then let them go to the different parts of the country.

‘But the opposition can come from all sorts of different quarters. In Gaza it’s been much more difficult because there have been a lot of different players locally who want to get involved, and how do you bring them all in? You’re not aware of that at the beginning, hence the need for these assessment visits.

‘We approached Medical Aid for Palestine: they were keen, as an NGO, to be seen to be using their money and their influence properly, and for us to go out and do this. But they just wanted us to go in and run a course – they said they’d be able to select the people for the first course, and we said no, we’ve got to go first – John and I had to go, we talked as doctors to the local doctors, and got some sort of feel as to who were going to the main players and who was going to try and resist it.

‘I think that we were lucky in Pakistan because we had the right guy, Kabir. He just took us straight to the Minister of Health, whom he knew intimately. Then he took us to the Governor, who lives in a magnificent palace – he’s an army man, who controls North West Frontier Province. It’s different from the rest of the provinces in Pakistan, and with that sort of authority behind us, everything just happened very smoothly.

‘So it varies from country to country. I have only been to Pakistan, India, Gaza, and Iraq. But there have been 43 countries now, altogether – South-East Asia, Indonesia, Central America, South America, and Africa – the main developing countries which are, in particular, poor nations.

‘It’s also in South Africa. There was a little resistance there first, because I think the white doctors felt that ATLS was the gold standard, but of course it is for the sort of first-world medicine that is practiced in white South Africa – but it ain’t for a lot of rural South Africa.

‘It’s very difficult to actually track the impact in any sort of academic way. We get feedback from the different groups – in Pakistan, for example, there was a bomb attack in the Sind Province last year. Shariq Ali, who was one of the guys who’s been very interested in taking PTC forward was involved in this, and he wrote back to say how effective it had been, in that they were all working from the same hymn sheet. But in terms of actually being able to say so many lives have been saved – it’s nearly impossible.

‘There have been spin-offs: John, as soon as the Pakistani earthquake happened, went out and worked with PTC teams at the site of the earthquake. And he saw that there was this village that had been completed shattered, and so through his charity he bought tents and he put the 200-odd villagers into tents. Initially they were going to rebuild locally, but the landowner, who was getting all the money, wasn’t pushing it down to the villagers. So John decided that the best thing to do was to buy ground about 10 miles away, and build a new village there! There are 36 houses that have been built now, at about two and a half thousand pounds each. So the whole village has moved – they’ve now got the freehold on that ground. And that just came through having got to know Pakistan and love the people.

‘In Pakistan we became aware that there was a very high incidence of maternal and infant mortality – particularly in the tribal areas. There are seven tribal areas, and they’re all self-contained and jealous of each other. There’s a very high illiteracy rate amongst the women, and they have birth attendants but no access to proper maternity care. And so what John did, in conjunction with a local Pakistani NGO in Peshawar, was to identify 15 young women to come out of the Khyber Agency (which is one of the tribal areas), and they’re in Peshawar now on an 18 month course in midwifery. And that’s fantastic because not only will they go back and be midwives, but they’ll be role models for the girls in that tribal area, because they will have come out and seen the world and then, going back, they’re empowered.

‘The future for PTC is in China – and that’s a colossal problem, and I’m not sure that we’re equipped to deal with it. Douglas Wilkinson – who is a medic in the TA; he’s just come back from Afghanistan – found me two days ago to say that it had finally looked as if he had got permission to develop PTC in China. Now, this has taken seven years. He’s had immense difficulties because of the politics of the whole thing. He’s got a large amount of money from somewhere to try and bring this forward, but dealing with the Chinese hierarchy has been extraordinarily hard. He wants me to go out with him in June to sign a ‘memorandum of understanding’ from each country when we’ve done the initial assessment, as to what we’re going to provide and what we expect from them. And that might work – but it will work, as in other places, by going to particular areas and hospitals, getting a core of people really interested in it and sufficiently interested to take it forward in their own country. That’s the strength of it, you see – ATLS is not like that. All ATLS instructors have to be trained by ATLS and only they are allowed to deliver the course; this is the strength of PTC, the way it can be propagated and adapted. It’s flexible.

‘I think it is a model – it illustrates the value of collaboration between communities and countries. In Baghdad, the first course will have two Pakistani instructors, and that’s great. It’s grown using people from one country who are really enthusiastic, to go to a neighbouring country, as in Pakistan and India. It’s the value of people moving into different countries that they’re not familiar with, getting to understand the problems. I had no knowledge about the injustices which the Palestinians deal with until I got involved.

‘We were horrified by what we saw in August. From the moment we left Jerusalem for the border – we had flown into Tel Aviv – there was a demonstration, and we asked our driver to pull over so we could see what it was about. There were two Palestinian homes, and at 6 AM the Israeli eviction police had gone into them, and the women were still in bed. And they had thrown them out, and two hours later, Israeli settlers were in their homes. This sort of behaviour by the Israeli police is appalling.

‘At the border, it was like a bloody great prison. You go through one door, and you have to stop and wait for a green light, and then you go through the next. Then you get to the other side, and the world is totally different, because it’s been totally bombed out – the buildings, the schools, the mosques, the hospitals. You can see it was once a beautiful place, but very little reconstruction has occurred.

‘I used to have the figures – you know, number of hospitals bombed and so on. There were around 1,500 Gazans were killed in the last conflict – it wasn’t a war, just an invasion – at the end of 2008, of which 40% were women and children. When you talk to Gazans, they tell you that the stories of human shields are absolutely untrue.

‘The health consequences are well illustrated by a special Lancet report – but it’s when you go there and you meet normal, decent people trying with families who are trying to make something of their lives and they tell you what they’re up against – these sort of humanitarian, human rights – call them what you will – abuses are going on all the time. Israelis regard Palestinians as just being dirt, they just want them to go away. And this is their whole policy towards Gaza – to drive it into total submission so they don’t want to live there any more. And they won’t win, eventually – they can’t. Twenty, thirty, forty years time, I hope the Palestinians will prevail.

‘I don’t know that there’s a duty for healthcare workers to learn more about these things. I think that they should certainly be encouraged. I think that some will be as I was – very focused on delivering a particular service to a particular group of patients in your area.

‘But I think that particularly young doctors should be encouraged, both during their medical school and during their early post-graduate time, to go to different countries, to go to poorer countries to see what they’re doing. And then some of them will, perhaps, get seized with the idea of what you can learn from them.

‘They’d be better doctors if they do.’

For more information about PTC’s work, go to their website
PTC is a registered charity (UK Charity No. 1116071).

Ben Warner is a third year medical student at Dundee University in the UK
benedict.warner(at)googlemail.com

A personal account of the undetected minefields in Cambodia and how they relate to the minefields in life, and the hurdles we face as future doctors. Jack Watson, who took a year out to travel between his 3rd and 4th year of medicine, tells us the story of Aki Ra who has spent a lifetime uncovering hidden landmines

He has gone by many names. When he fought in the Khmer Rouge against his own people of Cambodia, his name described his small but strong physique, his determination, or the way he cried when he was poked or teased. A crying soldier in such a ruthless regime that killed over two million fellow countrymen may seem out of place, but he was a child, a young boy. Orphaned by the regime he had to fight for, forced to carry a rifle, forced to track and kill down jungle paths and forced to lay landmine after landmine across his beautiful country. Back then, this boy had no idea of the man he would become – Aki Ra. His name continues to be famous for his invaluable knowledge of landmines, his bravery, and his strive to do good in a country still healing from the debilitating terrors of the past.

Aki Ra

The Khmer Rouge, under the ruthless totalitarian communist leader Pol Pot is renowned for the tens of thousands of deaths they caused through social engineering and genocide. Known as the Communist Party of Kampuchea (present-day Cambodia) between 1975 and 1979 they were responsible for killing 2.4 million Cambodians (1), a third of the total population (2), through torture, forced labour, starvation, and brutal executions in an attempt to create a pure, agrarian-based Communist society. Under this fanatical regime there was a forced evacuation of the cities, the whole population had to work on collective farms, and children, like Aki Ra, were used as a dictatorial instrument of the party. Children were uncorrupted and untainted with capitalism, so were separated from their parents and brainwashed the ideals needed to create an agrarian utopia, devoid of outside influence, education and hierarchy.

I chose to take a year out of medicine after 3rd year, not to intercalate, like many British medical students do, but to travel. At the time my justifications to my course-mates, family and professors focussed on a desire to see medicine in the developing world, where I felt it could be most effective, and was most needed. Now I know there was more to it than that. I wanted to learn, I wanted experiences, and most of all I wanted an answer. All of which I found in my short time in Cambodia when researching into landmines.

Three decades of civil war and violence, particularly during Khmer Rouge conflicts, has resulted in an estimated 6 million landmines in Cambodia (3). 98% of the casualties are civilian, according to records in 2002 (4). Unexploded ordnance and landmines cause a huge financial burden for a developing country, not only due to the cost of safe disposal, but the cost of supporting victims and the loss of land that could be used for agriculture, civil and commercial uses. In 2007, at least 350 people were killed from landmines and unexploded ordnance, and many more disabled, explaining why Cambodia has the greatest number of amputees per capita than any other country, with 1 person in 300 being an amputee; a total of 40,000. For me, nothing before has ruminated over and over again in my mind so persistently as the stories told by a child losing his leg by taking a shortcut home from school, or a father being killed when his cattle step on some unexploded ordnance. And nothing before has been as inspirational and motivating for me, proving that an individual can truly make a difference as much as the ongoing story of Aki Ra.

A musical band made up of land mine victims

Aki Ra represents the true power an individual has to bring change to society. Since 1995, he has been clearing unexploded ordnance and landmines in Cambodia and believes he has deactivated around 50,000 devices which could otherwise have maimed or killed local villagers. He worked for free, using a sharp stick and a knife to single handedly disarm each mine. In 1997, he turned his home just outside Siem Reap into a Landmine Museum, which gave him a medium to draw tourists’ attention to the sheer horror and destruction that landmines cause and the scale of the problem in Cambodia. Word spread of Aki Ra and his museum through photographers, humanitarian workers and journalists slowly leading to increased international support and donations. The Cambodia Landmine Museum Relief Fund (CLMMRF) was set up in 2001, which has enabled Aki Ra’s work to expand into a fully licensed non-governmental organisation (NGO). Demonstrating how determination can truly pay off he no longer needs to use a stick and knife as his sole tools, as following a trip to Britain he received training in demining and explosive ordance disposal. Cambodia Self Help Demining (CSHD) was established by Aki Ra last year and through this he has been able to create his own demining team, where he is putting his skills to greatest use by educating others to follow in his footsteps.

The government, along with other NGOs and charitable organisations, have been putting effort towards demining the vast swathes of Cambodian countryside covered by landmines. The government run Cambodian Mine Action Center has 36 demining platoons who operate across the country in teams dedicated in clearance, technical surveys, mechanical demining, dog demining, mine risk education and reduction and mass media campaigning. NGOs like the Mine Action Group’s (MAG) presence in Cambodia over 30 years since many on the mines were laid and bomblets were dropped resonates how damaged the country still is from warfare of the past. However, it also shows Aki Ra’s resilience and determination that his efforts could still make a difference. Rather than being discouraged by the very slow progress of large, highly specialised organisations that even had manpower and funding, he believed in his abilities to make a difference and kept going with his own input. For me, this represented the importance of persistence and resilience, the difference one person can make, and is something we can all learn from to remember throughout our medical careers. Aki Ra has worked for years to remove 50,000 mines through slow, laborious work, sometimes only clearing one out of six million in a day. He never became disheartened, though, and knew that each mine was a potential life saved. Although clearing one out of six million, is a very small difference, it is still a difference, and it is what this difference represents that we can learn from.

The minefields Aki Ra works in may be a far cry from the metaphorical minefields we will find ourselves in as junior doctors, but they may be just as scary on first encounter. Our minefields can also be paralleled with Aki Ra’s in the way we can learn from his resolute determination to demine, despite input from larger, more qualified organisations. If a minefield we are presented with is represented by a patient diagnosed with cancer, for example, we may at first be overwhelmed with how little we can do as junior doctors to cure and to help. The Consultants in Oncology with access to Radiotherapy and Chemotherapy may be represented as the large NGOs, with the experience and training to make a difference. However, this does not mean that we cannot as well. Just as Aki Ra knew every little input counted, we should also remember that our input in administering analgesia, comforting the patient, or reassuring the relatives is still making a difference, and part of the whole procedure of deactivating the minefield of the patient’s illness.

All of us have huge hurdles that lie ahead in wait of us as junior doctors. We have to deal with the ultimate complexities of life and death and come to terms with our patients dying whilst under our care. We learn medicine to help people, to make people better, to save lives, but of course this will not always be the result. I have had many a night following the cracks of the ceiling, considering the true gift a medical degree can give you, but also an overwhelming feeling of how little I can do with it. With every person that you help, there are 6 million in the developing world that you did not. Medical knowledge provides you with the opportunity, but an opportunity that can easily become overwhelming and distressing if one fixates on the people you are not making a difference to. I realised that travelling for me was about much more than a desire to see the world. I needed time to develop as a person, before I was ready to be a professional, responsible for patient’s lives and welfare. Junior doctors in their first postgraduate year are more likely to show symptoms of mental health problems, compared to others in the medical community (5). This highlights the importance of finding ways to cope and understand that everyone has their limitations. My concern that has been with me since commencing my medical studies about in our future job, our best is sometimes still not enough, was put to rest by a story Aki Ra told me:

[An old man walks along a beach. On the beach he sees a boy. The boy is walking along the beach, and constantly throwing starfish back into the sea. The old man watches the boy for a while and sighs. The beach is thousands of metres long. There must be millions of dying starfish on the sand. The old man tells the boy not to bother. The beach is too long, there are too many starfish. He cannot save them all. The boy with determination and belief in his eyes fixes the old man's gaze. He resolutely throws another starfish into the water and says "I saved that one!".]

If you want to Donate to the Landmine Relief Fund and support Aki Ra’s work go to www.landmine-relief-fund.com

Jack Watson is a fourth year medical student at Leeds University in the UK
ugm5jdmw(at)leeds.ac.uk

References

1. Rummel RJ, Statistics of Cambodian Democide Estimates, Calculations, And Sources Available at http://www.hawaii.edu/powerkills/SOD.CHAP4.HTM (accessed: 18/10/09)

2. United Nations Population Division. Available at: http://esa.un.org/unpp/ (accessed: 15/10/09)

3. Cambodia Mine Action Center Available at: www.cmac.org.kh (accessed: 23/10/09)

4. Landmine Monitor, Cambodia. Available at http://lm.icbl.org/index.php/publications/display?url=lm/2003/cambodia.html (accessed: 10/07/09)

5. Tyssen R, Vaglum P Mental Health Problems among Young Doctors: An Updated Review of prospective Studies Harvard Review of Psychiatry (2002) Vol. 10 No.3, p154-p165

Rufaro Ndokera writes on the wider impact of conflict on the health of individuals and society.

Our usual perception of a healthy balance between healthcare and politics in the Western world is sadly inapplicable to most of the developing world. In these countries, inadequate healthcare can be both a cause and effect of political unrest.  Armed conflict is often the overt presentation of power struggles within or between countries and is a major factor inhibiting the progression and development of global health initiatives. In areas where money is scarce only power and basic resources are left to fight for. (more…)

James Antoon writes on the underlying economics of health systems affected by conflict. 

The effect of war and conflict on local health care systems can be devastating and is often difficult to quantify.  Areas such as Iraq, Sudan, Palestine and Timor, where conflict is long term, all show a failure of the health care system to compensate for the increased need of medical care.  Unfortunately, the inability to survey and monitor as a result of violence and political posturing makes obtaining accurate heath care data difficult.  Qualitatively analyzing the effects, however, is not quite as challenging. (more…)

During the 1970s, subsequent to the oil industry being nationalized, a centralised system of healthcare was established in Iraq (1). This government subsidised system was based upon a Western model. It enabled the entire Iraqi population to access free healthcare (1). The country’s immense oil reserves were used to pay for medication and medical equipment, as well as for foreign healthcare workers (1). It is reported that before 1990, despite a severe curtailment of civil liberties, 97% of Iraq’s urban dwellers and 71% of the rural population had access to primary healthcare (1).

(photograph courtesy of MSF Canada).

The fate of healthcare in Iraq began to change in August 1990 with the outbreak of the first Gulf war (1). Furthermore, the UN Security Council took the decision to implement economic sanctions against the country, on the grounds that these sanctions would weaken Saddam Hussein’s grip on power (2). Within a period of six weeks, the US and its allies had dropped an estimated 88,000 tonnes of bombs, the equivalent of seven Hiroshima explosions, on Iraq (2). Water and sewage treatment plants, which had been damaged in the bombing, were no longer functioning at their optimal capacity (2). Cholera, typhoid and other water-borne diseases became rife (2). The economic sanctions that followed the war resulted in the impoverishment of Iraq and led to a downward spiral in the nation’s health (1).

Chronic shortages of food and medicine became commonplace (2). By 1997, an estimated one million children below the age of five were malnourished (3). Furthermore, as part of the sanctions imposed upon the country, an ‘intellectual boycott’ led to Iraqi doctors being cut off from medical and scientific developments happening around the world (2). This boycott prevented Iraqi doctors accessing the latest literature and restricted them having contact with their counterparts around the world (2).

A decade later, the mortality rate amongst children under the age of five had risen from 56/1000 live births in 1989 to 131/1000 (1). A large increase in the incidence of childhood cancers, widely believed to have been the consequence of depleted uranium shells being used by coalition forces, became noticeable in the years following the first Gulf war (4). Dr Muhammad Hilal, former chief paediatrician of a hospital in Baghdad, has commented that remission rates for childhood cancer plummeted from 70% in 1990 to around 6 or 7% by the end of the decade (2).

The already crippled healthcare system was to take an even greater battering with the onset of the invasion in 2003. In the initial stages of the war, 7% of the nation’s hospitals sustained damage and 12% experienced looting (5,6). The steady exodus of Iraqi health professionals, taking place throughout the 1990s, escalated (6). As the invasion took place without a UN mandate, it was not possible to effectively harness the knowledge of those individuals with expertise in post conflict health planning (6). In Iraq itself, numerous health experts, who were members of the Iraqi Ba’ath party, were dismissed from their jobs as part of the US determined process of ‘de-Baathification’ (6). Furthermore, in contrary to what is prescribed by the Geneva Convention (IV, article 18), hospitals received inadequate protection by the occupying forces (6). In 2004, there were even reports of humanitarian convoys being denied access to the besieged city of Fallujah, by the US and Iraqi army (7). The larger reconstruction contracts were bequeathed to private companies, rather than being placed in the hands of the WHO or UNICEF (6).  There is a risk that involving private companies in the reconstruction effort may lead to an emphasis on profit-making and a consequent detraction from humanitarian needs. Iraqi communities were largely excluded from decision making and planning in matters of healthcare provision (6). A rapid succession of health ministers since 2003, has further intensified the instability (6). Meanwhile, the training of health professions has suffered as medical schools are struggling to remain open. A 2008 report, released by the British NGO Medact, indicated that 5 years after the invasion, Iraq [still] has no comprehensive health policy or funding strategy (6).

(photograph courtesy of landstuhl hospital care project).

Since 2003, three-quarters of doctors, nurses and pharmacists have ceased working and half of these have fled the country (6). It has been estimated that only 9000 doctors and 15,000 nurses now remain in Iraq to serve a population of approximately 25 million (6). According to ‘Save the children’, the death rates amongst Iraqi children under five are approaching those of Sub-Saharan Africa (8). In the year 2005, one in eight Iraqi children died before they reached the age of five (8).

One area of healthcare that is currently much needed in Iraq but that has received inadequate funding since 2003, is that of mental health services (6). The mental health effects of the war upon the civilian population are immeasurable and their long-lasting repercussions are as yet unknown. Adult mental health services are limited while children’s mental health services are non-existent (6).

The toll that the war has taken on the physical and mental health of the Iraq people is perhaps particularly severe among the 2 million Iraqis who have received refuge in Syria, Jordan, Egypt or elsewhere in the Middle East (9). They now face the struggle of finding work and accommodation in their new surroundings (9). Syria, with a population of only 18 million has seen its infrastructure struggle to cope with an influx of 1.5 million refugees (10). As the cost of food and fuel has also risen sharply (10), there is evidence that some sections of the Syrian population have started to harbour grudges against the Iraqi refugees (10). Although the Syrian government has taken measures to limit the flow of refugees from Iraq, it has stated that it will not expel any of the refugees who are already in Syria (10).

Although the healthcare situation in Iraq looks bleak, there are steps that can be taken in order to try to resolve the crisis. For example, it is essential that the Iraqi people be at forefront in making decisions about their own healthcare. As recommended in the 2008 Medact report, Iraqi companies should also be given priority over foreign firms when it comes to bidding for healthcare reconstruction projects (6). Additionally, there is a great need for donors to come forward and provide financial aid for humanitarian projects within Iraq (6). The lyrics of US folk singer Pete Seeger’s Vietnam era song ‘Bring em home’ come to mind; they include the words ‘…the world’s got hunger and ignorance… you can’t fight that with guns and bombs.’

Tomasz Pierscionek
Medical Student
Newcastle Medical School, UK
tomasz.pierscionek@newcastle.ac.uk

References

1. UNICEF. Iraq Watching Briefs. Overview Report. Prepared by Sen B. , 2003.
http://www.unicef.org/evaldatabase/files/Iraq_2003_Watching_Briefs.pdf

2. Cappacio G. How many must die? Rethinking Schools Online 1999;13(3)
http://www.rethinkingschools.org/archive/13_03/iraq.shtml

3. UNICEF report. Situation Analysis of Children and Women in Iraq – 1997. Part two: Child survival, rights and basic needs. UNICEF 30^th April 1998    http://www.casi.org.uk/info/unicef/irqpt2a.pdf

4. Al-Azzawi S. Depleted Uranium Radioactive Contamination In Iraq: An Overview.      Presented at The 3rd ICBUW International Conference Hiroshima. August 3-6, 2006.    http://www.brusselstribunal.org/DU-Azzawi.htm

5. Garfield R. Challenges to health service development in Iraq, The Lancet 2003; 362: 1324.

6. MEDACT report. Rehabilitation under fire. Health care in Iraq 2003-2007. London: Medact, 2008.     http://www.reliefweb.int/rw/RWFiles2007.nsf/FilesByRWDocUnidFilename/EDIS-7B5MCP-full_report.pdf/$File/full_report.pdf

7. Ismael S. Fallujah – one year on. Briefing note. Doctors for Iraq, 2005.    http://www.doctorsforiraq.org/FALLUJA_ONE_YEAR_ON.pdf

8. Save the Children. Saving the lives of children under 5. 8^th annual State of the     World’s Mothers Report. Connecticut: Save the Children, 2007.    http://www.savethechildren.org/publications/mothers/2007/SOWM-2007-final.pdf

9. UNFPA, UNHCR, UNICEF, WFP, WHO. Health Sector Appeal: Meeting the Health needs of Iraqis Displaced in neighbouring Countries - Joint appeal by UNFPA, UNHCR, UNICEF, WFP and WHO. 18^th September 2007.

10. Al-Jazeera news report. Iraqi refugees swell pressure on Syria’s social services.       Published on 10^th October 2007. http://www.weshow.com/us/p/19226/iraqi_refugees_swell_pressure_on_syrias_socialservices

Kush Patel reports on the violence that occurred in Kenya following the elections earlier this year.

For many years, Kenya has been considered as a refuge for people fleeing their own country because of domestic turmoil. However, on 29th December 2007, shouts emanated from an angry throng that had gathered on the streets. Marching determinedly towards them was a battalion of riot police. Within seconds, the rioters hurled stones at the police, who counterattacked using bullets and tear gas. In other parts of the country, youths clutching machetes and sticks launched themselves upon opposing tribes. Events such as these set the scene for a blood bath that has resulted in thousands of people injured, dead or homeless. Several camps for internally displaced people (IDP) were set up all over the country. Governmental and non-governmental organisations (NGOs) such as Merlin, Medecins sans frontiers (MSF), the Red Cross, AMREF and others, deployed teams to provide humanitarian aid.

Post-election violence in Kenya results in displacement

photo source: savethechildren.org/au

Trauma victims requiring medical attention overwhelmed the medical facilities. When particularly violent clashes broke out, trucks full of injured or dead people arrived at hospitals, which in-turn became so over-crowded that patients were being treated on the corridors. A system of triage was implemented at many institutions, thus helping to treat the most severe patients first. (2,3) Patients were being rushed in with broken bones, stab injuries, blunt trauma and burns. Doctors reported certain cases where patients had sustained machete wounds that resulted in near-amputations. (3) Flying surgical teams were put on high alert, responding to violence in inaccessible regions. (4) In the worst hit areas, temporary first-aid posts were setup that quickly stabilized victims, while waiting for transport to hospitals. Any person who was critical and needed specialist care was air-lifted to the closest hospital. (3) Many of the victims were (and some still are) mentally traumatized from witnessing the violence or having lost loved ones. These people were given psychosocial support by medical personnel. (2,3)

Cases of sexual violence increased dramatically. These incidents took place both within IDP camps and outside. This will probably result in increased incidence rates of sexually-transmitted diseases, including HIV infection. Counselling and screening for sexually-transmitted infections have commenced in certain areas. (4)

Many people have been displaced and gathered at temporary IDP camps. At these camps severe public health consequences can manifest amongst the IDPs.. Four main reasons behind this are that the population is displaced, food becomes scarce, health care diminishes and living conditions worsen. Studies have shown that mortality rates are usually highest immediately after the migration. (1) Apart from the acute emergencies, an increasingly large number of IDPs need to be accommodated. At each IDP camp, tents were pitched, food and water was provided, sanitation and lavatory facilities were set up and medical camps were established. (2-6) Other essential equipment such as bed nets, (6) cooking apparatus, (3) and clothing, (2,4) was provided to the IDPs. Most IDPs had left their homes without anything. For many, important documentation was lost. Therefore, the task of registering the IDPs and getting new identification cards for them was set into motion. In order to keep the IDPs busy and lessen their emotional stress, some were given responsibilities in the camps such as cleaning. (2) Some NGOs have setup tracing agencies that help reunite lost family members.(4) Planes and helicopters had to be employed to deliver medical and other essential supplies to ill-equipped areas.(3)

The most prevalent diseases amongst IDPs are diarrheal diseases, measles, acute respiratory infections, and malaria. Additionally, many people became malnourished because of the lack of food. This aggravates diseased states and worsens the patient’s prognosis.(1) At a single camp, 541 consultations were done mainly for respiratory tract infections.(3) Most of these patients were children and many had a poor prognosis. Factors that contribute to a high prevalence of respiratory tract infections are: over-crowding, poor ventilation, inadequate shelter, and prolonged exposure.(1)
The measles immunization was provided for children.(3) For those who survive the initial illness, it can lead to malnutrition and vitamin A deficiency. Previously, measles has accounted for high mortality rates amongst children in refugee camps. However, it is less of a threat now compared to before 1990.(1)

Diarrhoeal diseases are a common phenomenon in IDP camps. Factors that contribute to their high prevalence are unsanitary conditions and unsafe drinking water. Cholera and dysentery are the main problems. In some IDP camps, diarrhoeal epidemics had broken out. These were usually treated with oral rehydration salts. However, any serious cases of diarrhoea were referred to a hospital.(4)

Kenya has a high prevalence of tuberculosis (TB) (7) and AIDS. (8) A lot of IDPs with TB or AIDS fled their homes without anything, including their anti-tuberculosis or antiretroviral drugs.(2,3,6) Adding to this, the number of patients attending HIV/AIDS clinics reduced dramatically.(3) This can have serious consequences on their health, as non-compliance results in the development of drug-resistance. Patients also become susceptible to opportunistic infections and their risk of morbidity and mortality increases.(8) One report mentioned a woman trapped at home, unable to gain access to a new dose of anti-retrovirals. As a result, when she was found by relief workers, an infection had set in and she had to be admitted to hospital.(9) Another hurdle with respect to anti-retrovirals is that many HIV patients were not getting adequate nutrition. This resulted in patients unable to tolerate their medication, further increasing non-compliance.(9) Patients with tuberculosis, face a similar scenario where drug-resistance develops.(4,7) The problem with this is that patients then require second-line drugs that are more expensive than first-line drugs.(4) Long-term effects of this may result in increased infection rates within the population. These 2 diseases were a major concern for the NGOs, who constantly held testing clinics, offered counselling and provided medication.(6,2,3) Thankfully this volatile situation has calmed down allowing people to piece together their lives. Medical attention has also improved in most areas. (6)

A correspondent from Merlin gave the following account of a typical day at an IDP camp:
The day usually starts off early, with a meeting discussing the day’s agenda. A clinic is setup wherever space is available (a vacant room or under a tree). Patients are then prioritized according to their level of urgency. Immunizations, HIV testing and counselling and treatment for minor illnesses are provided to those who need them. For those who require referrals to health centres or hospitals, transportation is arranged. Other team members conduct health education sessions for patients while they wait for their consultation.

Kush Patel
Imperial College London
kush.p.patel04@imperial.ac.uk

References
(1) Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu.Rev.Public Health 1997;18:283-312.
(2) Kenya Red Cross operations update. http://www.kenyaredcross.org/highlights.php?newsid=61&subcat=1, 2008.
(3) Medecins sans frontiers. http://www.doctorswithoutborders.org/news/report.cfm?id=2470, 2008.
(4) International committee of the Red Cross. http://www.irinnews.org/Africa-Country.aspx?Country=KE, 2008.
(5) AMREF Kenya news and press releases. http://kenya.amref.org/index.asp?PageID=10, 2008.
(6) Merlin newsletters. http://www.merlin.org.uk/Where-we-work/Kenya.aspx, 2008.
(7) O’Boyle SJ, Power JJ, Ibrahim MY, Watson JP. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). Int.J.Tuberc.Lung Dis. 2002 Apr;6(4):307-312.
(8) Frick PA, Gal P, Lane TW, Sewell PC. Antiretroviral medication compliance in patients with AIDS. AIDS Patient Care STDS 1998 Jun;12(6):463-470.
(9) BBC news on Kenya. http://news.bbc.co.uk/1/hi/in_depth/africa/2008/kenya/default.stm, 2008.

Rohan Radhakrishna’s study on Uganda’s “night commuters” was one of the winners of the first annual The Lancet-GHEC 2008 prize. An abstract of Rohan’s study – which will be presented at the 2008 GHEC conference – is provided below.

Context: An ongoing 22 year civil war has devastated Northern Uganda’s health infrastructure and caused the displacement of 1.8 million civilians. The displaced itinerant children in war-affected Northern Uganda known as the “night commuters” are a group who flee their villages and IDP (internally displaced person) camps at night for fear of rebel abduction and come into the town center for shelter and security. However, they have never been studied using randomized sampling, control groups, or mixed methods yet numerous policies have been implementing to improve their wellbeing. I arrived in Northern Uganda as a medical and public health student in 2006 working as a consultant for UNICEF and Caritas to conduct a needs assessment of the “night commuters” however the governor of Kitgum Province decided to abruptly close the 13 shelters were 4,500 children were finding sanctuary.

Objectives: To reveal the demographics of the “night commuters,” to understand their motivations for secondary displacement, and to promote evidence-based decision making by government, non-government organizations (NGOs), and humanitarian organizations through including the views of the populations they serve. My goal was also to use our research findings to convince the governor to not abruptly close the shelters and instead to slowly phase out the shelters using a case management approach for the extremely vulnerable children who weren’t able to return home immediately (AIDS orphans, disabled, child-headed households, formerly abducted children, children in congested homes etc.).

Design, Setting, and Participants: A retrospective cohort study of 720 “night commuter” children (aged 7-17) in 13 shelters in 1 district using stratified random sampling and a control group of 410 non-night commuting children (aged 7-17) in villages and camps for IDPS in the same district selected through random cluster sampling during July and August of 2006. Follow-up through an evaluation and prospective cohort study of 120 former “night commuters” in villages and camps in August of 2007. Quantitative surveys were administered in addition to qualitative methodologies using grounded theory: direct observation, key informant interviews (n=45), focus groups in 2006 (n=20) and focus groups in 2007 (n=8).

Main Outcome Measures: Sociodemographic information, housing situation, self-reported health indicators, sense of security, and motivations for displacement.

Results*: Night commuters were more likely to be partial or total orphans than non-night commuters. Lack of accommodation (44% p <.01) was found to be a greater reason for secondary displacement than lack of security (41% p<.01). Respondents cited other causes of insecurity after the rebels had left (thugs and local defense units). Over a dozen push and pull factors influencing their displacement were elucidated.

Conclusions: Respondents cited lack of accommodation and insecurity from non-rebel sources (e.g. thugs and local defense units) as major contributors to their secondary displacement which was not adequately considered by the government or humanitarian groups. Results helped construct a 10 Point Plan for responsible shelter closure adopted in consensus by stakeholders which led the governor to change his policy. I wrote 3 reports from my research leading to increased funding for health centers, schools, and shelter. This study revealed the need for developing minimum standards in population based research for displaced populations during complex humanitarian emergencies to promote more robust research, more representative sampling, and more locally informed decision-making.

*Full results available upon request. Some statistical tests are pending and a manuscript is being submitted.

In the second installment of his experiences, Paul Park tells us more about the situation in the Ugandan refugee camps

The clinic tent

An elementary school in the bordertown of Busia, Uganda housed the 2,000 refugees with each packed classroom inevitably creating a ripe environment for disease. In addition, the threat of violence was still present due to the proximity to the border and the similar tribal demographics in comparison to that of western Kenya. The Red Cross refugee site was located just 1.5 km from the local public clinic. Thus, without any medical infrastructure, Red Cross personnel were sending all refugees with health needs to the clinic. As you could imagine, the Red Cross staff was pleased to learn of my medical background and immediately gave me all clinical and public health responsibilities. I gave health education presentations (sanitation, personal and community hygiene, etc.) and continued to make referrals, in which I would write a brief history and physical to assist the overwhelmed clinic. Additionally, I initiated a patient record system. As a medical student, it is easier to feel competent when the safety net of your attending is always in place, and this scenario was no different. However, that was all about to change. (more…)

The situation in Gaza is forever changing. Anand Bhat interviews, Dorothea Krimitsas, the International Committee of Red Cross’s Media Relations Director for the Middle East and North Africa to find out more about the situation on the ground.

From kidnapped soldiers and BBC correspondents to travel blockades, the Gaza Strip in the occupied territories earns its reputation as a conflict hotspot. This article spotlights the siege of Gaza, the history behind it, and includes an account from the ground from those who work there.

The Gaza Strip is home to 1.4 million people in an area of only 360 square kilometers.  This densely populated land (3 888 people per square kilometer) is envisioned to be part of a future Palestinian nation along with the West Bank.

Gaza and the West Bank have been illegally occupied by Israel after the Six Day War in 1967. (1) (2)  Gaza was run by Egypt between 1948 and 1967 after the partition of the British Mandate of Palestine and the declaration of Independence of Israel.  Afterwards, the state of Israel built illegal settlements on the occupied land. (2)

Three years ago, however, Prime Minister Ariel Sharon controversially and unilaterally “disengaged” from the Gaza Strip by evicting Jewish settlers and withdrawing the Israeli Defense Forces (IDF). (3)  In 2006, the Islamic fundamentalist group Hamas entered electoral politics and won a majority in the Palestinian Authority National Assembly against the secular Fatah Party.  Also in 2006, Palestinian militants kidnapped the Israeli soldier Gilad Shalit which led to Israeli incursions into Gaza.

After political spats and two mini-civil wars with Fatah, Hamas engineered a violent takeover of the Gaza Strip in 2007 throwing out the Fatah-dominated security forces. (4)  The international community condemned and cut off aid to Hamas and looked to the West Bank government for any peace negotiations.  Ending foreign aid to the Hamas Gaza government has caused enormous economic hardship for a very foreign aid-dependent society.  Militants began firing Qassam rockets into Israel from the Gaza Strip.

In response to rocket attacks and the kidnapped soldier, Israel declared Gaza to be a “hostile territory” at war with Israel. (5)   The Strip is now under siege and sealed off from the outside world.  Recently, Israel also announced it would stop fuel from entering the Gaza Strip.

Between such violence on both sides, I found the 2007 report by the Red Cross, “Dignity Denied,” interesting. (6) The International Committee of the Red Cross (ICRC) declared that humanitarian aid is insufficient for the situation in Gaza and urged a political solution, an intriguing break with its neutrality in such conflicts.  From the report it reads:

“Throughout the occupied Palestinian territories, in the Gaza Strip as well as in the West Bank, Palestinians continuously face hardship in simply going about their lives; they are prevented from doing what makes up the daily fabric of most people’s existence. The Palestinian territories face a deep human crisis, where millions of people are denied their human dignity. Not once in a while, but every day…

“The dignity of the Palestinians is being trampled underfoot day after day, both in the West Bank and in Gaza.  Israel’s harsh security measures come at an enormous humanitarian cost, leaving those living under occupation with just enough to survive, but not enough to live normal and dignified lives.”

To find out more about the situation on the ground, I interviewed the person in charge of the International Committee of Red Cross’s Media Relations for the Middle East and North Africa, Dorothea Krimitsas, on the siege in Gaza and its medical and humanitarian implications as opposed to the media’s usual focus on the political, ethnic, and religious implications.

Q:  What is the situation right now in the Gaza Strip and why should young medical professionals care?
“The Israeli blockade, although not fully hermetic, remains quite tight. With the decision taken by the Israeli Supreme Court allowing cuts to fuel deliveries to Gaza, no improvement can be expected. In other words, supplies reaching Gaza are still strictly limited to essential humanitarian shipments. The number of trucks currently entering the Strip is down to a trickle compared with the situation before June 2007 [when Hamas took over]. As a result, the needs of the population are far from being met. The amount of goods currently entering Gaza has fallen down dramatically and the downward spiral of conditions for Gazans will continue until all parties concerned reach a solution to the current impasse.

“Hospitals facilities are directly hit by these shortages. They are still operating on the emergency mode only, as their fuel reserves do not allow them to run all services, which would be needed for a population of 1.5 million inhabitants. Chronic diseases and non-urgent interventions are no longer dealt with. Drugs and disposables are on short supply, although the ICRC is keeping a constant watch on their needs and is re-supplying their stocks as quickly as possible. It is hard to say when the situation will get any better for the medical profession and their patients in Gaza.”

Q: How does the siege affect doctors, hospitals and patients?  Do you have any figures on patients harmed by the power cuts?
“Doctors, nurses and patients are all affected by the present situation. The shortage of fuel and electricity is the major problem they are facing. Patients in Gaza used to benefit from a better level of medical care until the restrictions became fully effective in June 2007. Since then, and in a more acute way with the additional electricity cuts, the medical profession is experiencing severe lacks affecting the treatment of ordinary surgical or medical cases, and the follow-up of chronic diseases. This is a major concern for a population already weakened by all sorts of deprivations.

“We know of one ventilated patient who died at Ahli Arab hospital during the process of switching over from the main power plant to the generator. The ICRC does not have statistics on how the restrictions are affecting health.”

Q: What are the casualties on either side of this conflict?  What is the status of the kidnapped Israeli soldier?
“There are ongoing hostilities between Palestinian fighters and Israeli soldiers, with almost daily casualties. In Gaza, most cases can be treated on the spot. People wounded by rockets in nearby villages in Israel such as Sderot are also treated on the spot or evacuated to better equipped Israeli hospitals if needed.

“So far, ICRC delegates did not get access to the Israeli soldier in Palestinian hands. The priority for the ICRC is to get at least a sign of life. Despite all efforts this has not yet materialised.”

Q: Are any international laws or treaties being broken on either side?
“In its recent publication “Dignity Denied”, ICRC emphasized the immense suffering caused by decades of occupation in the West Bank and Gaza Strip. Non-respect of international humanitarian law applicable in occupied territories (the Fourth Geneva Convention) is a constant concern for ICRC delegates who are monitoring the situation of the Palestinian population.

“Likewise, ongoing hostilities putting at risk the life of Israeli civilians have to be considered. Legitimate security concerns, on one side, and the right to live a normal and dignified life, on the other side, are the minimal requirements.”

Q: It is alleged that Palestinians use ambulances to smuggle weapons to attack Israelis.  Israel has bombed ambulances in the past.  Are these charges true?  Is attacking medical personnel against international law?  “Attacking medical personnel is forbidden under international humanitarian law.  Medical  personnel, facilities and vehicles, must be protected at all times, thus the importance to respect red cross and red crescent emblems, and the ‘magen david adom’, which is the emblem of the Israeli national society. The ICRC regrets that, in many conflict situations, misuse of emblems or lack of protection of the medical mission are reported.

“To improve the situation, its delegates around the world keep disseminating the most important rules to be respected in times of conflict. For instance, throughout 2008, the ICRC is running a campaign to raise awareness on the specific rules which are linked to this obligation of respect. It will address the Palestinian Territories and also Israel Defense Forces.

“As a matter of policy, the ICRC does not comment publicly on specific events or violations of international humanitarian law, but discusses its findings and recommendations directly with the parties concerned. Whenever the ICRC is aware of attacks on medical personnel or facilities, it intervenes with the parties concerned.”

Q: What is Egypt’s role in the sealing off of Gaza?
“Egypt is a sovereign country which is sharing part of its border with the Gaza Strip. After the recent events, it has imposed a close control of this border. It is not up to the ICRC to comment any further.”

Q: Did Israel truly disengage from Gaza in 2005?  Do Gazans have the right to use their coast, airport, and borders?
“As a matter of fact, in spite of the departure of Israeli occupying forces from Gaza, Israel still imposes a very strict control of all access roads to the Strip, be it by air, sea or ground. As a result, no trade can be operated by Gazans. Only essential humanitarian goods are allowed, and even this vital aid is sometimes subject to further restrictions.”

Q: What are you asking from the international community?  Why has the Red Cross made such a statement?  Is there something fundamentally different that warranted the need for a “political solution?”   

“The ICRC has been continuously present in Israel and the Occupied and Autonomous Territories for the last 40 years. The situation on the ground is further deteriorating. To prevent more hardship for the population, it is necessary to go back to the same levels of access for humanitarian goods and personnel, which existed before June 2007, and the delivery of essential humanitarian goods must be secured in the long run. But it is high time that those responsible within the international community and among the direct actors realise that humanitarian action is no substitute for political action. As the ICRC’s head of operations for the Middle East and North Africa said in a statement on 13 December 2007, “In the current situation, humanitarian assistance alone is insufficient. It cannot and should not be a substitute for political action.

“The ICRC firmly believes that only prompt, innovative and courageous political action can change the harsh reality of this long-standing occupation, restore normal social and economic life to the Palestinian people, and allow them to live their lives in dignity.”

Conclusion
Will the situation improve any time soon?  Will there be a political solution?  A recent poll of Israelis by the newspaper Ha’aretz finds that 64% of Israelis now favor direct negotiations with Hamas with only 28% are opposed, (7) a faint sign of hope for the region.  It is only too logical to ask for peace and dignity for both sides.

Anand Bhat
Second year Medical Student
University of Texas Medical Branch
Texas, US
akbhat@utmb.edu

(1)  U.N. Security Council Resolution 242

(2)   “Forty years on.“  The Economist : March 24, 2007

(3) Oliver, Mark.  “Soldiers evict Gaza settlers.“   Guardian : August 17, 2005.

(4)  Shult, Christoph.  “Hamastan” vs. “Fatahstan“  Der Spiegel : June 19, 2007.

(5)  Ravid, Barak and Shlomo Shamir.  “Cabinet declares Gaza ‘hostile territory.”   Ha’aretz: September 20, 2007.

(6) Dignity Denied. ICRC 2007

(7)  Verter, Yossi.  “Poll: Most Israelis back direct talks with Hamas on Shalit.” Ha’aretz:  February 27, 2008.

James Matheson interviews some experts on the potential of this exciting new specialty

In May 2006 the American Board of Physician Specialties announced board-certification in Disaster Medicine and, in the United States, a new specialty was born. The Florida hurricanes and a heightened awareness of the terrorist threat in the wake of 9/11 had demonstrated America’s vulnerability to disaster and concerns were high about the ability to respond.

Dr Maurice A. Ramirez, founder-chairman of the American Board of Disaster Medicine (ABODM) explains why: “The most ominous words ever uttered by a disaster preparedness expert were that given the current state of hospital preparedness and the rate at which facilities are becoming disaster ready, there will be no meaningful level of preparedness in this decade unless someone blows up a hospital.

(more…)