Keir Philip writes on the ’Convoy to Cape Town’, a major event raising awareness of maternal health in South Africa.

On the dusty floor of Cato Manor township near Durban, the air pulsating with the collaborative efforts of South African and British musicians from the White Ribbon Alliance ‘Convoy To Cape Town’, I sat surrounded by 15 children from the local orphanage and asked them ‘Why can pregnancy and giving birth be dangerous?’

I already knew the issues; I’d read them in a book. 80% of maternal deaths result from direct obstetric complications including haemorrhage (bleeding), infection, unsafe abortion, hypertensive disorders and obstructed labour. The children knew the issues; their mothers had died because of them. And I already knew the statistics; I had read them in a report. One woman dies every minute of everyday from pregnancy related causes. The children knew the life those statistics described. In one of those minutes, on one of those days, that dying woman was their mother. As soon as my friend MC Black Moss had translated to Zulu, pens hit paper. The responses became images, which in turn became banners. By circumventing language barriers through the universal language of art, each child’s voice was given a chance to be heard, ‘People can’t afford to travel to hospital’, ‘men are beating women’, ‘some women don’t have a break from work around birth’. And, unsurprisingly, ‘the virus is killing mothers’, as HIV/AIDS is the leading cause of maternal mortality in South Africa. Through raising awareness of the situation for women, which was the intention of the convoy, politicians can be made accountable and forced to make the changes that women are entitled to. This should be seen as a fundamental step in tackling these issues in an effective and sustainable manner. (more…)

Shafqat Inam writes on the health inequities experienced by indigenous peoples. 

In the last century public health initiatives, increasingly sophisticated hospital systems and effective pharmaceuticals transformed the face of healthcare. However, indigenous peoples, long-term inhabitants who have strong cultural and historical links with their environment, continue to suffer poor health outcomes around the world: they have poor living conditions, higher rates of infant and maternal mortality, and are disproportionately burdened by infectious and chronic disease. (1) It must be ensured that the plight of an already marginalised group is not forgotten amongst the shifting sands of world politics. I will argue that indigenous peoples in developed and non-developed countries must be given the opportunities to ride the wave of globalisation to close the health gap that currently exists. (more…)

Amelia Cutts writes on conflict and child health, with a particular focus on Haiti and Sudan. 

The concept of power and politics affecting the health of a nation’s population is not a new one. Political instability is a common cause of poor health in a nation, leaving many civilians without access to clean water, adequate food supplies and medication. Young children are affected more than any other group in the population as they are more susceptible to malnutrition and are more likely to contract diseases such as cholera due to lower levels of immunity. (1)

During the American civil war in the 1860s, the health of the population suffered immensely. The primary reason being that there were few, if any, men left to work on the farms that sustained the towns and villages with food, as they were all at war. Estimates suggest that between 320,000 and 650,000 men died during this conflict, but many of these were from disease rather than as a result of direct conflict. Some sources say that this was as much as 3% of the population, having a profound affect on the lives of civilians at the time. (2) (more…)

James Matheson writes on how healthcare in Iraq has been shaped by past and current politics. 

This article examines political factors before and after the 2003 US-led occupation, contributing to Iraq’s failing healthcare system, documented by Medact’s reports. (1)

Saddam Hussein came to power in 1979 with early healthcare improvements evidenced by decreasing child mortality, but his repression of disfavoured populations by withholding medical services (2) and a combination of his belligerent actions and their political exploitation internationally reversed this trend. The West’s support of an eight-year war with Iran evaporated when Saddam invaded Kuwait in 1991 threatening oil price stability and, after military defeat by a US-led coalition, Iraq came under UN sanctions.

Some claimed 1.5M people died from sanctions. (3) Certainly mortality more than doubled in under fives in the south. (4) In the autonomous Kurdish region, protected by allied intervention, mortality did not increase allowing suggestions that Saddam’s influence, rather than sanctions, was to blame. When the ‘Oil for Food’ programme began, however, health improved. (4) (more…)

Ilona Dekkers writes on her visit to Rwanda and the state of the health system there.

In April 2007 I had the great opportunity to visit Kigali, the capital of Rwanda together with 24 other young Europeans from all Member States of the European Union. We accompanied the European Commissioner for Development and Humanitarian Aid, Louis Michel, on an educational visit to Rwanda. The young people from the 25 Member States of the EU were the winners of the Development Youth Prize awarded at the first European Development Days held in Brussels.

Rwanda, one of the most beautiful countries in the world, has a dark history. During the 100 days of genocide from April to July 1994, almost one million Rwandans were killed. The genocide was triggered by the assassination of the Rwandan’s Hutu president Juvenal Habyarimana when his plane was shot down above Kigali airport on April 6 1994. Hutu extremists wanted revenge for the murder and began to systematically murder Tutsi and moderate Hutu. The genocide has left massive scars on this tiny central African country. (more…)

Sarah Nathaniel, Stephanie Wells and Abi Perini discuss healthcare provision for the homeless and their personal experience in this field as medical students. 

Two men sit on a park bench. A middle-aged man with eyes fixed to the floor holds a cigarette in the fingers of his right hand and in his left he grasps a half empty bottle of cider. He smells terrible and his beard is matted with the remains of last night’s dinner.  At his feet lie a bundle of carrier bags, the sum total of his possessions. The other man is younger, clean shaven with short well kept hair and the aroma of aftershave. He is wearing an open necked shirt with a pair of smart trousers and sits reading a copy of The Times drinking his morning coffee. At first glance it may appear that these two men belong to completely different worlds, but they both have one thing in common; they are both homeless.

Judgement, we are all guilty of it. For most of us, the tramp on the bench would be what automatically springs to mind when thinking about homelessness. How many of us if we were sitting opposite would have guessed that both of these men were homeless? Personal encounters with homeless individuals, views held by our peers and the typecast portrayal of homeless characters by the media, all contribute to the formulation of our own ideas and opinions about homeless people. But what does it actually mean to be homeless? How much of the homeless stereotype that we believe to be true is actually true? And what is the significance of all of this to medical students and other healthcare students? (more…)

Gurdeep Mannu writes on the philosophy of utilitarianism and how it can be applied to medical ethics. 

Osler famously describes medicine as an art, and we as medical students are future practitioners of this art. Science and art do not mix more so than in the ethics and morals by which we practice. It is essential for medical students worldwide to appreciate the moral implications of the medical decisions they make. This is despite the fact that philosophy and bioethics is a topic which is to a large part neglected in many undergraduate medical curriculums in spite of recent reforms. This article reviews the common philosophical theory of utilitarianism and examines this doctrine in the context of a medical dilemma.

This article first gives a brief account of the theory. It then discusses its various forms and respective strengths and weaknesses. These points will then be explored in the framework of a modern ethical dilemma in healthcare in order to ascertain whether utilitarianism in all its variations, is sufficient to explore all of the ethical dimensions of such a problem a student or doctor may face. (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

Over the last decade, the inequitable gap between rich and poor has widened both in the UK and globally.  Urbanisation has continued, most notably in industrialising countries as more people go in search of employment opportunities.  In fact, 2008 was the first year that more of the world’s populace lived in an urban rather than a rural setting (1).  Global travel and tourism has also grown due to relatively accessible and affordable air travel (2).

These above forces have led to an increasing number of tourists arriving in cities with a growing slum dwelling population.  While the majority of tourists still visit the most famous sites and attractions within a particular country, an increasing number are choosing to pay for poverty tourism, or “poorism”.

Tours have the potential to perpetuate the poor health and poverty cycle

These trips usually involve spending a day walking around a major slum with a local guide who was born and raised in that area.  Poorists will have the opportunity to visit local initiative programmes from health clinics and schools to sewing sweat shops, sewerage systems and wells.  The tour may even include a refreshment break in a slum house (3).

In Delhi, a city of 18 million, Western tourists can pay around $5 to spend a few hours watching the daily lives of Indian slum children - playing cricket around landfill sites, selling chewing gum to and polishing the shoes of passing commuters (4).  Similar excursions are offered in the Kibera district of Nairobi, Africa’s largest slum as well as Rio de Janeiro, Cairo and Soweto in Johannesburg.  Interestingly ‘ghetto’ tours can even be taken in New York (3).

Writing for the Observer, Amelia Gentleman argues that these trips are voyeuristic and exploitative (3).  Local people unfortunate enough to live in such conditions are gawked at and may be pressured by the tour organisers into acting up their impoverished situation (5).  This may include drinking stagnant water or glue sniffing to increase the sense of pity and subsequent donations to the ‘charity’ which has organised the tour.  How much money actually reaches the affected children and households and what difference this actually makes is unknown but certainly the tours have the potential to perpetuate the poor health and poverty cycle.  On the other hand, the international visitors and their foreign currency can demand change and small scale improvements, and it is better the tourists see beyond their 5-star hotels and safari jeeps (4).  Additionally, a charity organising poorism trips in Delhi have opened a day centre school which can provide some shelter and security to the street children (6).

Whichever view is taken, the tours demonstrate the inextricable gap and ignorance between the lives of the rich and poor.  There must also be something slightly perverse in enjoying a holiday observing profound misery.  To improve access to clean water, affective health care systems and to safeguard against the effects of climate change, the poor and the poorists alike should demand and will require much more investment than small initiatives and entrepreneurial start-ups.

Edward Armstrong
Foundation Year 1 Doctor
North West Thames Foundation School, UK
edward.armstrong02@imperial.ac.uk

(1) Population Reference Bureau (2007). World Population Highlights; 62: 3.

(2) Matsumoto (2004). International urban systems and air passenger and cargo flows: some calculations. Journal of Air Transport Management; 10; 4: 239-247.

(3) Gentleman A (2006). Slum tours: a day trip too far? The Observer. Accessed on-line http://www.guardian.co.uk/travel/2006/may/07/delhi.india.ethicalliving

(4) World Resources Institute (2006). Poorism in India. Accessed on-line http://www.nextbillion.net/blogs/2006/06/01/poorism-in-india-development-through-enterprise-or-lower-class-exploitation

(5) Lancaster J (2007). Next stop squalor. Accessed on-line http://www.smithsonianmag.com/people-places/squalor.html

(6) Salaam Baalak Trust (2008). Accessed on-line http://www.salaambaalaktrust.com/shelters.asp

Sandra Zaeh writes on the the mental health challenges in Sierra Leone. 

By any Western account, the mental health system in Sierra Leone is struggling.

With one trained government psychiatrist, little funding for psychiatric drugs and mental health facilities, and few opportunities for mental health care outside the capital of Freetown, the majority of mentally ill patients are beyond the reach of biomedical care for mental disorders.

To fill the void, Sierra Leoneans turn to alternatives like traditional healing and spiritual practices to address their mental health needs, options that even Western-trained experts consider crucial to maintaining the country’s mental health. And yet, the balance is tenuous - and, without an infusion of financial and human resources, may not be sustainable. (more…)