Global public health has recently been the focus of increasing attention from the interdisciplinary worlds of policy and politics, academia, private foundations, civil society, the media and the general public. This is likely the result of the convergence of a number of seemingly disparate features of the current public health landscape and is not surprising given recent current events – the earthquake in Haiti, healthcare reform in the United States, and aging populations all over the world experiencing rising rates of chronic diseases, such as cancer and diabetes [1]. This article will explore some of the most salient recent trends in global health and its affiliated fields to understand in what direction the discipline is moving and offer some modest recommendations as to how the field may adapt to an increasingly globalized world. This article will focus on education and training, human rights, technology, civil society, new money and public-private partnerships (PPPs) to give the reader, who may not be familiar with the broad scope of this field of study, an overview of some recent developments in global public health and their consequences for practitioners.

The spread of HIV/AIDS, SARS, H1N1 and various non-communicable diseases has confirmed that “diseases do not need visas”. The field of global health has emerged as a significant public health focus, though a clear definition of the discipline remains under debate. Indeed, visionaries such as Julio Frenk see them as one and the same [2], while others, for example the Consortium of Universities of Public Health have a more complex view in which global health is simultaneously a notion, an objective, and/or “a mix of scholarship, research, and practice” [3]. The definition the group ultimately presented read “global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.” Despite the burgeoning popularity of global health, however one may define it, training and educational opportunities remain relatively scarce. In the United States, for example, only about 20 universities (out of hundreds) offer a graduate degree program in global health – formerly known as “tropical” or “international” health – and programs at undergraduate institutions are few and far between [4]. There are even fewer programs for global health study in developing countries [5] where the need is arguably greatest. The noticeable recent surges of academic enthusiasm for the field of global health have not been sufficiently matched by significant increases in training opportunities, especially for younger students [6].

A second concept that has emerged to change the face of global health is that of health as a human right. Often still understood from within its conceptual framework or as solely a process for transformation, [7] health as a human right has actually become quite mainstream and certainly is increasingly operationalized by a variety of private foundations, bi- and multilateral organizations and governments. Many countries have even incorporated the right to health into their constitution. Development of the rights-based approach came about in reaction to pervasive stigma and discrimination around the early stages of the HIV/AIDS epidemic and has since diffused to many areas of public health, especially within low resource settings. Whether the rights-based approach is used explicitly or implicitly, it is clear that it is more frequently being applied to programming, rules and regulations along with the right to education, employment and development [8]. This focus may have decreased disparities within countries, but strangely enough has the potential to increase certain disparities between countries as some adopt these principles and others do not. It is thus the role of public health practitioners, policy-makers and government officials, to use a human rights framework in his or her approach and to encourage others to do so as well. Only then will this field become fully integrated.
A third and quite transformational evolution in the field of global health has been the development of new technologies, as well as the new use of old technologies in innovative ways. For example, the challenges presented by the disaster in Haiti and the associated public health issues such as water, sanitation and the spread of disease, gave rise to alternative ways to manage crises. Cell phones were especially useful for mapping damage, coordinating relief efforts, reuniting families, donating money and for helping ordinary people find their voices amidst the rubble [9]. Media attention in the form of live feeds and real-time interviews certainly contributed to the world’s understanding of the crisis and their subsequent outpouring of financial, technical and religious support. Apart from the crisis, service provision and data collection is slowly but surely being revolutionized by the use of cell phones to administer checklists and provide real-time training and support [10]. The idea is that better quality data, monitoring and evaluation will yield more effective uses of resources and more successful future programming.

A fourth development has been the rise of civil society, especially international non-governmental organizations (NGOs) or civil society organizations (CSO). Their increasing prominence, connectedness, and centrality to global health priority-setting cannot be understated [11]. The NGO community has successfully lobbied, instructed and altered the work of multilateral, bilateral and government agencies and is global in scope and influence. For example, successful lobbying on drug access and pricing and tobacco advertising has proven “transnationally” transformative in the support of the public interest [12]. Spurred themselves by new technologies [13], civil society organizations (CSOs) are able to occupy the unique position of both “watchdogs as well as collaborators” [14]. NGOs may have, however, muddied the waters of global efforts towards accountability, though new NGOs have sprung up to monitor the old [15].

Lastly, the increasing popularity of alternative ways and means to improve global health has generated the need and opportunity for creative new partnerships. For example, private foundations such as the Bill and Melinda Gates Foundation have provided enormous financial support for both mainstream and neglected global health issues from sexual health programs for urban sex workers in India to striving to eliminate onchocerciasis (river blindness) in Colombia [16]. Additionally, public-private partnerships (PPPs) are more often being used to leverage private sector efficiency to solve public sector problems [17]. Both have undoubtedly contributed significantly to the often scattered and uncoordinated field of global health with new reincarnations of functional organizational behavior, technological and human resources development, and program management. The realization of the importance of working with both the public and the private sector is essential to global health practitioners’ effectiveness. The fields of business, international relations and finance have certainly contributed to significant advances in global health and we must learn as much possible from this interdisciplinary collaboration.

In light of the developments discussed above, representing only a select few that I find most illustrative, the evidence that the face of global health has been and still continues to evolve is quite convincing. With such growth and development come both significant challenges and opportunities for both practitioners and the public. We tend to point our fingers, in the event of program failure or frustration, at a lack of resources or of political will. But I point mine – in the spirit of constructive criticism – at the scattered understanding and capacity of this emerging field. The palpable lack of accord in priority-setting and the dearth of training opportunities for interested young people have handicapped our ability to tackle the real public health issues. The current relative lack of consensus and preparedness in the wake of expanding interest in and commitment to global health is concerning. It seems, therefore, critically important to cultivate academic, civil society and political enthusiasm for the topic in order to assure that future generations have the focus, capacity, and knowledge necessary to set priorities and work together.

The field of global health is currently almost exclusively pursued at higher institutes of learning in the developed world, to its detriment. With decreasing life expectancy in Sub-Saharan Africa, an obesity epidemic in the United States, and indigenous populations all over the world suffering significantly poorer health than their non-indigenous counterparts, public health should be one of the most active areas of work and study in our world today. However, both low- and high-income settings lack the training opportunities needed in emerging public health fields. Spatial and geographic methods, low-resource-appropriate health technology, complex data management, monitoring and evaluation, demographics of aging, methods for accountability and a better understanding of health economics, systems and policy are just a few of these neglected sub-fields. The challenge is therefore to translate new and welcome enthusiasm into the skills and capacity to enable young people to contribute to the field in a both a constructive and a cooperative manner.

Most importantly, the field of global health should, indeed, be global [18]. It should certainly not be simply a discipline intended to increase a university’s prestige, attract funding, or ever perpetuate the image of professionals from low-income settings as not working in “global health” [19]. It is therefore necessary to increase training opportunities in the low-resource-settings themselves – not for international students, but for locals – and to improve programs already in existence so that they may meet growing needs and interests. New and creative approaches are needed, however, as currently employed programs and incentives do not seem always to attain their desired results [20]. For example, Dr. Lincoln Chen and colleagues in 2004 proposed a health systems approach to improve workforce capacity in low-income settings using a multidisciplinary local approach benefiting from “appropriate international reinforcement” i.e. supplemental funding [21]. Their suggestion to mobilize a collaborative strategic plan can certainly be applied to other aspects of training in global health whether it be integrating human rights into government policy, collaborating effectively with civil society, human resources strengthening by task shifting, or improving efficiency through new partnerships and technologies. The framework’s call for “immediate action backed by simultaneous learning” certainly applies to the need for improved training and capacity building in all areas of the discipline.

The birth of global health and its growing pains can be seen as both an opportunity and a challenge in our globalized world of scarce resources. The changes in the discipline described above can be seen as wonderful developments to be taken advantage of. It is important in discussions of global public health not to bemoan our lack of resources or lack of political will as barriers to achieving our goals. More important is the need for pertinent training [22] and an ability to integrate solutions and work together, whether it be to combat the emergence of a highly infectious disease or disseminate a new checklist to improve patient care. All worthwhile initiatives lack funding, but the difference between those that achieve something and those that do not is the way in which they use the limited resources they have. Nowadays, the field of global health can boast enormous enthusiasm, media coverage, technological partnerships and advancement, human rights street cred, sophisticated techniques for data collection and analysis, and reach far across sectors from business to anthropology. We therefore must stop bemoaning what we don’t have and cultivate what we do.

Laura Nolan Khan
Department of Global Health and Population,
Harvard School of Public Health
LKHAN(a)hsph.edu

References

1. Economist Intelligence Unit. Breakaway: The global burden of cancer— challenges and opportunities. 2009. Available from: http://livestrongblog.org/GlobalEconomicImpact.pdf
2. Fried LP, Bently ME, Buekens P, Burke DS, Frenk JJ, Klag MJ, Spencer HC. Global Health is Public Health. Lancet. 2010;375(9714):535-537.
3. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN et al. Towards a common definition of global health. Lancet. 2009. 373(9679):1993-1995.
4. Association of Schools of Public Health. Accessed March 22, 2010 http://www.asph.org/document.cfm?page=1107
5. Gewin V. The global challenge. Nature. 2007;447(17):348-349
6. Riegelmen RK & Albertine S. Recommendations for Undergraduate Public Health Education. 2008. Association of American Colleges of and Universities & Association for Prevention Teaching and Research.
7. Gruskin S, Mills EJ, Tarantola D. History, principles and practice of health and human rights. Lancet. 2007;370(9585):449-55.
8. Tarantola D, Byrnes A, Johnson M, Kemp L, Zwi A and Gruskin S. 2008. Human Rights, Health and Development. Technical Series Paper #08.1. Sydney: The UNSW Initiative for Health and Human Rights, The University of New South Wales.
9. Giridharadas A. Africa’s Gift to Silicon Valley: How to Track a Crisis. Accessed March 22, 2010 http://www.nytimes.com/2010/03/14/weekinreview/14giridharadas.html?ref=todayspaper
10. D-Tree International. D tree approach. Accessed April 6, 2010 http://www.d-tree.org/index.php?pid=7
11. Matthews JT. Power Shift. Foreign Affairs. 1997;76(1):50-66.
12. WHO. Strategic Alliances: The role of civil society in health. Discussion Paper No. 1. December 2001.
13. Reich MR. Reshaping the state from above, from within, from below: implications for public health. Social Science & Medicine. 2002;54:1669–1675.
14. Shaw RP. The Interface between CSOs and the World Bank; An Input to Global Health or Global Harm? 2007. Workshop on “Civil Society Organizations and Global Health” Wall Summer Institute for Research, June 25-28. The Peter Wall Institute for Advanced Study. University of British Columbia Vancouver, Canada.
15. Christensen J. Asking the Do-Gooders to Prove They Do Good. New York Times. January 3, 2004 B9: 1
16. Bill & Melinda Gates Foundation. Progress Against Neglected Tropical Diseases. 2009.
17. Reich MP. Public-Private Partnerships for Public Health. 2000. Nature Medicine. 6(6): 617-20.
18. Merson MH & Shaw KC. The Dramatic Expansion of University Engagement in Global Health. Implications for US Policy. 2009. Center for Strategic & International Studies. Washington, DC.
19. Macfarlane SB, Jacobs M, Kaaya EE. In the name of global health: Trends in academic
institutions. Journal of Public Health Policy. 2008;29(4):383–401.
20. Bärnighausen T & Bloom DE. Changing Research Perspectives on the Global Health Workforce. 2009. NBER Working Paper 15168.
21. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M. Human resources for health: overcoming the crisis. Lancet. 2004;364:1984–90.
22. Keiger D. The Buck Goes Here. 2010. Johns Hopkins Magazine. Baltimore, MD.

By Amirah Dunwell

Amirah Dunwell is a 15-year-old high school student living and studying in North London. She plans to study drama, dance, and media in her final years at school. She is also hoping to gain a place at the prestigious Central School of Speech and Drama to study for a degree.

WHEN Clint Walters first walked into our house, I didn’t know anything about HIV, other than that it was a sexually transmitted disease (STD). All it was to me was three letters. Clint was a friend of my mum, (who she met clubbing) and he would often pop in for a coffee, a cigarette, and a chat about the day. One day, when he was staying the night, I opened the fridge to find some bottles of pills that I hadn’t seen before. “What is all this stuff for?” I asked mum. “They’re Clint’s. He’s got HIV,” she said, very matter-of-fact, like she was talking about making a cup of tea. I didn’t understand what it meant, so asked her to explain. Mum told me a short version of Clint’s life story-that he had caught HIV from his second boyfriend when he was 17, and had battled the disease ever since, including trying to set up his own charity as well as endless charity work for others. There had been times when he had been very sick, but the medication had helped him recover and now he was leading a normal life.

But what was HIV, and what does it do? I wanted to know. Mum explained that it is an infection that affects your immune system, and that if it’s not treated, it can lead to other infections and a person dying. “Oh my God, is Clint going to die?” I asked. But mum said that modern medication means that the virus can be kept under control, and Clint’s immune cell count (or CD4 cell count) had recovered such that he was in a very healthy state. Apart from taking the medication, his life was as normal as hers or mine.

Not long after this bombshell, mum and I invited Clint to my 14^th birthday party. About 60 friends came, and pretty much all of them commented on Clint’s bubbly personality, smile, and twinkling eyes. How would they feel if they knew, I wondered, that he had this serious illness?  

Any person my age (AGE 15!), by now, will have had some kind of sex education, just like I have. Like most girls, the subject is first discussed in primary school (where teachers explained what sex was), and then at 11 we are taught the science behind it all. But this education focuses not on sexually transmitted diseases, but on stopping getting pregnant, puberty, and other growing pains. I consider my mum to be very streetwise, and I thought, if it’s taken me this long to find out the facts around a condition as serious as HIV, then what chance would those around me have?

I didn’t have to wait long to find out what people’s perceptions of HIV were. One day a teacher brought up the subject of HIV in a lesson, and asked us, what do we know and feel about the disease. The class was made up of 35 girls, and I was shocked by some of the ignorant answers they came up with. It was clear straight away I was the only person who had met someone with HIV. Some of things shouted out were “everyone will hate you if you catch HIV”, “it’s a gay disease”, and “you die if you catch it.” Someone else shouted if you use a condom, you can stop yourself catching it-at least they got that part right.  I sat there thinking that no-one could ever have spoken to my friends or other classmates about HIV. I was worried that we were all going to be adults soon, and these were the opinions we would be taking with us.

Soon, my newfound knowledge about the condition would be put to the test, as mum came home from work to say Clint had caught swine flu (H1N1 influenza). It was at the peak of the swine flu epidemic. I had swine flu myself, mum had had it, and my classmates were dropping like flies with the disease, like they were in all schools. What was it that was so worrying? I asked mum. She explained that swine flu was hitting people with underlying conditions like HIV harder, and so that meant Clint was at risk of developing complications. At least Clint wasn’t worried about it, but nor did he worry about anything really. In the end, Clint did catch swine flu, but it was quite mild and all he needed was a few days in bed.

Back at school, I told the girls about what was happening. Firstly that Clint had HIV. “Oh my God are you lying?” some said. “Is he going to die?” was another common response, along with “Are we ever going to see him again?”. Then I explained what mum had explained to me, that he was quite healthy, but that swine flu could cause complications if it got him. My friends admitted they were as ignorant as I had been-they too knew it was an STD, but nothing else. “But he looks so normal,” one friend said. “I would never have guessed he had HIV,” said another. I agreed with them—Clint was just as normal as anyone. I thought to myself that if every student could meet someone like Clint to have HIV explained to them, there would probably never be a bad reaction to such news again.

Now I wonder if there is a way that families could be educated better about not just HIV, but other sexually transmitted diseases. Meeting Clint made me realise these things were not just in textbooks, they were real. My family has no problem discussing serious things like this, but I know others do. Some parents just can’t deal with this kind of thing. Could they be sent stuff through the post or something, or would they just throw it in the bin rather than discussing it with their children? And some families have religious beliefs that make things even more difficult. But unless a way is found, class after class will go through every school without a clue about the facts behind HIV.

Meeting Clint has made me think about how teenagers my age, and younger or older, could be better educated about HIV. The things we are taught at age 11 need to be broader, and repeated yearly so that we don’t ever forget, because these are vital things that we shouldn’t forget. How about a health class every week or two weeks in school, where these things can be discussed openly without any fear of strict or difficult parents interrupting?  

And it can’t just be about lessons in school, or ‘the talk’ from our parents. There are so many other places and events where these things could be brought up in a non-threatening way. I attended a music festival in London earlier this year in which goodies were being given out for free in return for accepting an info pack and doing a urine Chlamydia test.  Ideas like that can encourage teenagers to find out things, without having to feel embarrassed about asking someone in authority. Some kind of workshop, to which pupils could travel to for the day, and find out everything they need and want to know about sex, STDs, and other life issues could be another way to go. Get young people excited and looking forward to finding out about these things, instead of an embarrassing traditional lesson.

Many schools, both my own and those of friends, have a school nurse, but unless they are sick people don’t want to go to her. If it was someone specifically meant for sexual health information and advice, maybe people would use that service more? Someone like Clint would have been ideal, due to his young age and outgoing personality. Young people will connect with people they see as similar to them.  And no single plan is going to suit everyone; I think a variety of things are needed to cater for the range of personalities that are in every group of teenagers.

And for some people, maybe it’s not another person they need to explain things. I use Facebook often. Some people use it even more and are holed up in their rooms for hours at a time! So what’s wrong with using Facebook to educate people? Quizzes about different STDs, or life situations, so people can find out where they stand. And if they need to find out more, a contact number or website where they can go to get it. Again, this could help educate teenagers who are too scared or embarrassed to ask their parents, teachers, or other adults for advice.

And television has its part to play. It’s nothing new to play out a serious illness in a television character, but most teen dramas are reluctant to take on such a big fish as HIV. They go for the safe stereotypes like anorexia, depression, self-harm, suicide. One well-portrayed character with HIV could reduce stigma for a generation. But it would have to be very carefully done, with every aspect explored, and shots of the person getting on with life positively, just like Clint did.

I had barely adjusted to my rapid education on HIV when some terrible news arrived. Clint had passed away, aged just 30, and Mum and I were distraught. In a few short months he had taught me so much, and my life has been so much richer having met him. A few days later, I went to the park, a newspaper containing Clint’s obituary was inside. Some girlfriends who knew about Clint’s HIV wanted to read it, but so did some boys who had met him but didn’t know his status. Their reaction surprised me and gave me hope for the future. Instead of the prejudiced comments I expected to hear, they came out with “wow, he had a tough life battling with HIV”, and other respectful, comforting words.

A few months later, I’m thinking what can I do to make sure all the work that Clint did to reduce HIV stigma was not in vain? I want to play my part in preventing prejudice. Mum and Dad recently splashed out on a video camera to help me with my drama course. My schoolmates and I have already used it to make a mini-drama about schizophrenia, and Mum and I agree that a fitting tribute to Clint would be a film on HIV. I’d want to show to the whole school first, maybe get them to take a HIV knowledge quiz before and after. Then maybe try to get it onto a bigger stage. Whatever happens, Clint will never be forgotten.

In this article, Sirina Keesara discusses the issue of misinformation as a barrier to use of family planning and slowing of population growth in Ghana.

From the invention of the birth control pill in 1960, and the subsequent proliferation of family planning programmes, access to contraception has expanded incredibly (1). Knowledge of at least one method of contraception is now nearly universal in almost all areas of the world, with pills, injectables, and male condoms as the most cited examples (2). Unfortunately, this improvement in knowledge has not been accompanied by an increase in contraceptive use. Use is especially low in Sub-Saharan Africa (2). The juxtaposition of these two findings seems to indicate that people who know about contraception don’t want to use it, probably because they want more children. However, this conclusion is inconsistent with the finding that more than 137 million women throughout the developing world do not want another child but are not using anything to prevent pregnancy (3). So why aren’t they using contraception if they know about contraception, but do not want to continue growing their families?

Researchers who have worked on this question for the past half century, have created a theory of fertility behaviour that attributes this gap in knowledge and practice to factors such as cultural traditions, low education rate, high mortality rate, and lack of women’s autonomy (4). The video at girleffect.org is one of the best popular culture products of this accepted theory. Using only animated words the video conveys a simple and powerful message: empower girls, change the world. At the start of the video, we see the word “girl” associated with the burdens of “child”, “husband,” “HIV”, and “hunger.” Then, with the introduction of “education”, all the burdens fall off, the music changes from gloomy to hopeful and the video rushes full force into the solution of education, micro-loans, and opportunity for girls to fix the world. The viewer is so elated by an elegant solution to complex problems, that many don’t notice one key omission: the family planning factor.

Rewind and click pause to the point when all the burdens fall off. How exactly are these burdens supposed to magically fall away? Giving a girl education prevents babies? No, not directly- only a condom or a set of pills (or any other form of contraception) can do that. Well, a girl will be able to obtain contraception if she has the opportunity for an education and a career… correct? Not necesarily!

The key, but faulty, assumption here is that women and couples will rationally weigh the costs (money or education lost, time that could be spent working, effort) and benefits of having a child and then will take necessary precautions to prevent any unwanted pregnancies (5). The first problem with this assumption is that, many times, children do not come as a product of rational decisions, but rather as a product of the passion of one moment. Therefore, because we have sex for reasons other than reproduction, we will produce babies without consistent contraceptive use. The second problem with the cost-benefit rationale is that it sets the cost of obtaining and using contraceptives very low. However, barriers to contraceptives are far greater than cost and distance to a family planning clinic. As revealed by interviews I conducted in Ghana, we have been successful in giving couples access to family planning, but we have failed to address other less tangible barriers.

Among the wide variety of barriers that exist in the field (6) many programmes have done little to explore or address issues such as misinformation surrounding contraceptives. Through interviews I conducted with women in Ghana, where the unmet need is s among the highest in the world at 34% (7), I found that the key element which holds women back from using contraception is misinformation; rumors, myths, and other pieces of faulty information prevent women, and especially young girls, from using contraception. If they believed that birth control will harm their body, health, or future fertility, they would not use it, even if a pack is placed directly into their hands. For example, the following woman working in a marketplace in the capital city, Accra said:

Sirina: you are afraid of the medicine. Okay, but what do you think will happen if you take it?
Woman: It will disturb you. Because if they say that if you use the medicine, it will destroy the womb. Because I am afraid of not having birth. If you don’t have birth, you won’t feel well in your self
Sirina: you don’t feel well as a woman.
Woman: yes! you are not feeling well. Some of them, they insult you if you don’t have births

Some even believed that abortion was safer than contraceptive pills because “it happened only once”, whereas contraception stifled fertility for an extended time. Abortions in Ghana, though legal, are highly restricted and largely unsafe.

Contrastingly, when the fear of infertility was taken away, many women jumped at the possibility to use family planning and limit their fertility. For example, one woman, who had thirteen children, was adamantly against the use of family planning because it went against God’s will. However, when she was asked, “would you use family planning if you were sure it was safe and it wouldn’t endanger your fertility?,” she answered: “oh of course.” This response was astounding because she seemed to have abandoned her religious reasons within a matter of seconds. When this question was included in all the subsequent interviews, the answer was almost always an emphatic “Yes!”

Furthermore, I found that women are badly in need of a method to control their fertility. One women was pregnant with her fifth child and had decided that she was going to take the “risk” of using family planning because she was so desparate to stop having children:

Interpreter: Well, she knew someone who had a problem with the family planning and they were trying to discourage her from it.
Sirina: But then why did she end up using it? I don’t understand why she would go for it.
I: That’s what I said that she wanted to give it a try and take the risk.
S: but if she took the risk she might not have been able to have babies again?
I: And she would have blamed herself for that. But she didn’t mind, she wanted to do it because she didn’t want any more [babies].

This widely found “intangible barrier” of misinformation meant that women had an ingrained belief that family planning was bad for fertility, and this belief played a large role in women’s reluctance to use it even when they wanted to control their fertility. Furthermore, it seems that when misinformation is removed women will act on their desire to have fewer children and will make a quick reversal of attitudes towards family planning. This can happen even without improvement in formal education or socioeconomic status. Other intangible barriers have a similar effect on women. For example, fear of maltreatment in clinics is potentially a huge hurdle. Despite Ghana’s Ministry of Health’s effort to train nurses and create youth-friendly clinics, these clinics are few and far between. For example, when I worked in a Family Planning Clinic, I witnessed the nurses “counselling” (scolding) a young client who wasn’t married before “getting into those things”. The girl was then forced to change her preferred method of contraception from the injection to the pill, because according to the nurse, that injection could make her sterile (it can’t), and she was sent away thoroughly embarrassed (8). Therefore, we can see that intangible barriers can be as significant or more than physicial availability of contraceptives.

Although intangible barriers are elusive to tackle, they are not insurmountable. For example, Iran, Bangladesh, and Thailand have all been able to ensure access to contraception for many women through community based distribution systems (10). In Iran, the increased governmental attention to family planning access and sexual education dropped the fertility levels (9) from 6.0 children/woman over her lifetime in the 1970s to 4.3 in the 1990s and then 2.1 in 2005 (10) – and inside a traditional culture. Case studies such as these raise questions about the validity of the accepted fertility behaviour theory; they show that fertility levels can drop and population growth can slow without improvement of other socio-economic variables. Therefore, it seems to imply that some factor, other than development, must influence fertility behaviours.

A newer theory of fertility decline, the opportunity model (11), says that women and couples will use contraception if they understand fertility regulation is an imaginable possibility. That is, if they believe they can use contraception without harmful side effects, they will want to use it and demand its availability! Think about it this way, before the internet we didn’t demand a connected web of information through which we could communicate almost instaneously. This demand was created by making such technology an imaginable possibility. Now that it is in our realm of possibility, almost nobody can live without it. In the early years of the internet, skeptics claimed that people would have to learn too many new skills to make use of it. However, Marc Andreesen, the creator of the first browser, replied “People will change their habits quickly when there is a strong reason to do so, and people have the innate urge to connect with other people- when you give them a new way to connect with other people, they will find it objectionable not to be able to”(12). Similarly, many academics have said that people would not adopt family planning because it would require too much behaviour change. However, I would argue that family planning opens doors to new options for women, and when they have access to contraceptive methods, along with correct information backed up with safe abortion, they will find it objectionable not be able to control their family size. In our work studying fertility preference and behaviours in Ghana, this pattern was clear; it seemed that women who learned that family planning was safe and easy to use, in other words who believed family planning was an imaginable possibility, would demand it and start to use it. Considering this theory we assume that the number quoted for unmet need is grossly underestimated because women with many intangible barriers may not realise that they have an option to control their fertility and thus may not express this desire.

This sheds new light on why family planning programmes in the past have not been as successful as expected. We need to redefine the way we think about barriers and tailor programmes to address these issues. If we are able to do this, we will be able to give women control over their own fertility, and by doing so slow rapid population growth. We cannot afford to ignore rapid population growth as this sole factor can ruin all our plans for the Millenium Development Goals and exhaust our world’s resources (13). If we ignore this issue, we are ignoring women’s rights and the rights of the future generations to come. We should encourage the international community to re-direct their attention towards family planning and understand its relevance in the underlying issues of health and development.

Sirina Keesara
Sirina.Keesara(a)ucsf.edu

References
1. Robinson WC; Ross JA. The global family planning revolution: three decades of population policies and programs. Washington, D.C., World Bank, 2007

2. Khan, Shane, Vinod Mishra, Fred Arnold, and Noureddine Abderrahim. Contraceptive Trends in Developing Countries. Calverton, Maryland, USA: Macro International Inc. 2007. DHS Comparative Reports No. 16.

3. Sedgh, Gilda et al. Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method. New York: Alan Guttmacher Institute, 2007: Occasional Report No. 37. Accessible at http://www.guttmacher.org/pubs/2007/07/09/or37.pdf

4. Notestein F.W. Economic problems of population change. Proceedings of the Eighth International Conference of Agricultural Economists. London, Oxford University Press. 1953

5. In Gary Becker’s Nobel Prize winning book, Treatise on the Family, he uses economic principles to explain decisions and actions that pertain to the dynamics of the family. He includes on chapter about the Demand for Children in which he terms children as a high cost commodity and explains childbearing as a parent’s rational decisions about their “consumption” of children. ( cite his book)

6. Campbell, M.M. Sahin-Hodoglugil N. & Potts, M. Barriers to Fertility Regulation: A Review of the Literature. Studies in Family Planning, 2006: 37, 87-98

7. Gribble, Jay. Family Planning in Ghana, Burkina Faso, and Mali. Population Reference Bureau. April 2008. access on December 30th, 2009 at http://www.prb.org/Articles/2008/westafricafamilyplanning2.aspx

8. Keesara, Sirina. Barriers to Fertility Regulation for Ghanaian Women. Presentation at 137th annual APHA conference. Accessible at: http://apha.confex.com/apha/137am/webprogram/Session27587.html

9. Fertility levels are measured by Total Fertility Rate (TFR), the number of children that a woman (women, or a woman – hjave or has) would have in her /or their lifetime if fertility rates are constant. Replacement lvel fertility, in which each woman has the number children only replace the population is 2.1.

10. Gubaju, Bhakta, GUBAJU, BHAKTA. Fertility Decline in Asia: Opportunities and Challenges The Japanese Journal of Population. March 2007; 5:1

11. Campbell M, Bedford K.The theoretical and political framing of the population factor in development Phil. Trans. R. Soc. B 2009 364, 3101-3113.

12. Friedman, Thomas. Chapter 2. The World is Flat: A Brief History of the Twenty-First Century.

13. All Parliamentary Group on Population Development and Reproductive Health, “Return of the population Growth Factor: Its Impact on the Millenium Development Goals” (HMSO, London, 2007). www.appg.popdevrh.org.uk Accessed on December 27th 2009

Leonardo Da Vinci’s Vitruvian Man

‘Conscience without science is weak and ineffective, but science without conscience is dangerous’

I started off as a student of science, enamored by the human ability to think, create, imagine and understand the world around us. Fascinated by the use of scientific tools and technology to demonstrate and answer the why’s and how’s of the way things work.

Our educational edifice is built of bricks of the basic sciences and a smattering of the arts, these subjects are seen as separate as oil and water. But in the initial steps of a career in medicine we are taught that “medicine is an art and a science”. This dichotomy of science-art is hard to comprehend as a raw medical student unexposed to the practice of medicine. Especially as many of us may feel we are about to embark on what we perceive to be a logical, precise journey into the medical sciences.

The Science

Prior to the study of clinical medicine we learn the basic sciences- biology, chemistry and physics which then transcend into the anatomical, physiologic and biochemical realm. Here mechanisms and functions– gross, molecular, biochemical and pharmaceutical interactions are elucidated. We learn through scientific methods about how our bodies generally function and develop a basis for understanding disease alterations in humans.

The ‘scientific method’ refers to the application of scientific techniques for investigating, acquiring new knowledge, or correcting and integrating prior knowledge. To be termed scientific, a method of inquiry must be based on gathering observable, empiric and measurable evidence, which is subjected to specific principles of reasoning. A scientific method consists of the compilation of data through observation and experimentation, with formulation and testing of a hypotheses.[1]

We then move on to acquire clinically relevant knowledge, which is also based on strict scientific observation. Every technique from taking a blood sample, palpating for a spleen, auscultating the heart and lungs, are learned by recognizing specific systematic protocols, using tools and techniques that have been practiced and studied, developed and proved through years of evidence based medicine. Evidence-based medicine aims to apply the best available evidence gained from the scientific method to medical decision making [2] . It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment), refining and validating the information continuously. As not all statistically viable data is clinically relevant and treatment methodology applied on one individual may not be applicable on every other.

Medical science dictates such an impersonal, objective character, which does not relative to personal thoughts and experiences. “Medical practice depends on generalizations that can be reliably applied and scientifically demonstrated. Without understanding people as objects in this way, there can be no such thing as medical science” without which, the practice of medicine would be impossible [4].

The doctor observes signs and symptoms, experiments to improve clinical evaluation, tests for signs, hypothesizes, collects data, and samples and tests them for a conclusive confirmation which concludes in a diagnosis. Then the treatment modalities are initiated and are given similar scrutiny to assess, refine and continue development of advances in the field of medicine. Till this stage the process seems straightforward and well charted out.

The Art

By heading to the clinics often the expectations and experiences flow into a direction diametrically opposite to a logical scientific view.

In art, as understood by artists themselves, the quality of the achievement cannot be measured. It cannot be determined by comparing it against some norm or transforming it into such neutral entities as quantities and figures. Similarly, every case does not present as pictured in the book as patients may present in different stages, after taking some treatment or be unique due to other reasons. Along with the disease aspect, patients are scared, uncomfortable, bored and frequently down right miserable. Understanding the individual patient as encountered in practice and comparing the individual, with himself and not on a broad research perspective is an essential requirement. The art encompasses human skills as well as demonstration of technical clinical skills[5].

The human art lies in knowing that everyone deserves dignity, respect, empathy and care. Empathy is not just sympathy; it implies feeling of deep concern for the overall welfare so as to restore the patients help or mitigate suffering [6].Building the human touch of a physician- patient interaction helps both parties. Ask an unscripted question [7], smile or shake a hand. Good patient care necessitates that the patient actively participates in his own management; without trust this is difficult. Our skill in this regard is to understand and respect individual needs, their socio-economic and familial status and provide a non judgmental environment for them to be able to confide in us. This can only be achieved when we can assure them that our probing questions and examinations will help us help them. The art of medicine is the art of healing, not just treating, not even just curing. Technology will not assuage the mental torment, fear, anxiety that may follow illness.[6]

The need to show care is not just to be a good human being, in today’s litigious society, it is a necessity, patients are less likely to sue if they think you care [8]. The patient needs to be informed and reassured about the tests, procedures and treatment so that, they can understand the pros and cons of therapy and weigh the benefits and risks of complying or not complying with treatment.
Even in end of life care the art of medicine is paramount, palliative care may mean that hope of cure is lost, but the hope of care is still present. Palliation is often a neglected aspect of the medical treatment, at many times due to the inadequacy of the expanse of care which the treating doctor is qualified or capable of providing. A poor prognosis does not call for an abandoning attitude. Acquiring all these skills may sound difficult, some are naturally gifted a friendly gregarious demeanor and others not, but if the determination to master the art of skillful communication is there, the art of medicine can be acquired through observation, study and training by anyone.

The art of medicine also lies in the skillfulness and technique of demonstrating clinical skills, which are acquired after years of practice [5]. Clinical skills are required to elicit knee jerk in an uptight individual, distinguish bronchial from vesicular breathing in a crying scared child etc. Even more important is to know what treatment should be given under which circumstance. Even non- medical issues need to be understood and accounted for, such as understanding patient compliance, factors related to their occupation or economic status. Old people may find it difficult to comply with complicated regimens and those without support systems may need a different treatment approach. Ethnic sensitivity is required in today’s international world, and peoples’ cultural and religious preferences should be accorded respect, to facilitate care. Trousseau, a French physician ended one of his clinical medicine lectures thus ‘For mercy’s sake gentlemen, let us have a little less science and a little more art!’[6]

Fallacies

Modern day medicine is essentially science, however there is good science, bad science and pseudoscience. There is also good, bad and ugly art as art is in the eye of the beholder. Learning the appropriate demeanor for a situation requires sensitivity. A major faux pas would be a silly, joking attitude while breaking a life threatening illness or a stern attitude towards anxious parents before a surgery. Hippocrates himself claimed that they were the real doctors, unlike their opponents or any other ‘idiotes’( the Greek for ‘laymen’ from which we derive the word idiot.) [9]. One may acquire knowledge about a certain condition like obesity and some may come to blame a patient or believe they are ‘idiotes’ for they did not take the proper precautions and their ignorance towards themselves may have led them to you, but this arrogance is uncalled for. A combination of bad science and bad art may lead to unproductive results as exemplified by many medical charlatans, seen through the ages. They claim to possess more knowledge or skill than they really do and have managed to build a large following.

Dr Abrams’, the father of radionics invented a diagnosing machine in 1910 called the “dynamizer”, which was a box with a jungle of wires. One wire ran to an electrical source, and another was attached to the forehead of a health person. A drop of blood from the patient was obtained on filter paper was placed in it. Following this he would percuss the abdomen – and for reasons never made clear was made to face west – by listening he would then diagnose the disease. His logic – the spine has nerves which vibrate, the dynamizer picks the vibrations from the blood sample and transmits them amplified back to the spine and are then sent to various parts of the body where it can be detected. His theory was that every disease has its own “vibratory rate”. He also built an oscilloclast to impart vibrations to drugs, a reflexophone for diagnosing over the phone. Radionics devices contradict principles of biology and physics, and no scientifically plausible mechanism of function is posited. In this sense, they can be described as magical in operation. No plausible biophysical basis for the “putative energy fields” has been proposed, and neither the fields themselves nor their purported therapeutic effects have been convincingly demonstrated. No radionic device has been found efficacious in the diagnosis or treatment of any disease. [9,10,11] Many doctors are also able to “charm” patients into needing hospitalization for minor problems, or assenting for expensive and unnecessary treatment; this ‘art’ is unworthy of the noble profession.

Combining the Two

‘Conscience without science is weak and ineffective, but science without conscience is dangerous’

Good doctors use their personal judgment to affirm what they believe to be true in a particular situation. Their knowledge is not purely subjective, for they cannot believe just anything; and their judgment is made responsibly and with universal intent, i.e. they take it that anyone in the same position should concur. It is practical wisdom -medical practice demands such judgments on a daily basis. The good doctor is able to reflect on diverse evidence and to apply it in a particular context. But this too cannot be anything one imagines by hit and trial. Judgment cannot be reached by logic alone. Here medical practice as art and science merge. [3]

As students we can only learn, however this quest should not be blind or rigid. We need to apply ourselves to attain the goal of assimilating the true essence of both the science and art of our chosen field. We should learn by understanding the scientific basis of all our skills and the significance of how to apply them. Data and methodology should be available for careful peer scrutiny by other researchers and be given the opportunity to verify results by attempting to reproduce them. We should be open to changes and in turn not be complacent in our approach and hope to be spoon fed all knowledge, [13] for no one person possesses all knowledge and right knowledge is dynamic in nature.

As doctors of tomorrow we are bestowed with a huge moral, social and ethical responsibility. We as the palanquin bearers of the world of medicine must strive to uphold the virtues entrusted on us- which is possible only by a balanced amalgamation of both Science and Art in their purest forms.

Bhavna Seth is a second year medical student at Lady Hardinge Medical College, University of Delhi.
bhavna.seth(at)gmail.com

References:

1. Scientific method: Merriam-Webster Dictionary. 11th Edition.

2. Elstein AS. “On the origins and development of evidence-based medicine and medical decision making”. Inflamm. Res. 2004 53 Suppl 2: S184–9

3. Saunders J. The practice of clinical medicine as an art and as a science. West J Med. 2001;174(2): 137–141.

4. Guttentag OE. The phrase art and science. California and western medicine 1939; 50(2) : 86-87

5. The Forgotten Art of Healing and Other Essays by Farokh Erach Udwadia Oxford. University Press; 2 edition (Aug 1 2009)

6. Better: A Surgeon’s Notes on Performance by Atul Gawande, Metropolitan Books; 1st edition (April 3, 2007)

7. Wu AW, Huang I, Strokes S et al. Disclosing Medical Errors to Patients: It’s Not What You Say, It’s What They Hear. 2009; 24(9): 1012-1017

8. Eureka! The Birth of Science by Andrew Gregory Publisher: Icon Books Ltd; 1st Edition (5 Nov 2001)

9. National Center for Complementary and Alternative Medicine.”Energy Medicine: an overview”. Retrieved 2008-02-09. “In the aggregate, these approaches are among the most controversial of CAM practices because neither the external energy fields nor their therapeutic effects have been demonstrated convincingly by any biophysical means.”

10. Fads and Fallacies in the name of science, Martin Gardner, Dover Publications, Inc. New York, 1957 ISBN-10: 0486203948 ISBN-13: 978-0486203942

11. Raines K. Quack Cures and Radionic. JW Research Journal. 1996; 3(2).

12. Chan A, Peets A. The student’s perspective. Clin Invest Med 2000;23(1):103-4.

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

Today’s feature comes to us from Ana Zelić, Kristina Špoljarec and Tin Knežević, who discuss the current and future status of palliative care in Croatia with Professor Anica Jušić.

We talked to professor Anica Jušić, a neurology specialist, who has been promoting paliative care in Croatia for many years. In 1994 she organized The first Croatian Hospice and paliative care symposium,and is a founder of Croatian hospice friends association. Since then she organized over 40 symposia and wrote over 30 articles. Since 1999 she runs the first home paliative care team. Considering the upcoming congress, we decided to get an insight into this subject.

First we would like to ask you is the development of paliative medicine in proportion to the increasing percentage of the elderly population? Or does it depend on the incidence of malignant diseaeses? How can it be explained?

No! Paliative care began to develop significantly in the 1950’s. The discovery of symptome reducing drugs, such as pain and anxiety (non-steroid antiinflammatory drugs, anxiolytic drugs…) ,and the renewed validation of opiates as powerful analgetics encouraged this to happen. Due to the administration of these drugs, the presence of medical staff, especially doctors, during the period of dying became inevitable. Before that, providing care during the difficult time of dying was assigned to family members, volunteers an sometimes nurses. On the other hand, many intensive care units were established, where patients die surrounded by machines, almost completely dehumanized, and parted from their loved ones. At that time the term ˝good˝ death was often mentioned, which connotes the patients right to choose the location of his/her death, most people choose their own homes. This kind of way to die, in the presence of your loved ones, is a better way to die, because it increases the quality of the remaining time to live. This is also done by drug administration, especially analgetics, to reduce pain. Psycho-social problems also need to be dealt with, since many of such occur in these situations. Finally, it comes down to dealing with existential and spiritual issues. The main goal is the patients acceptance of the inevitable and death fear reduction. This way patients can condone to parting with their loved ones, and even give comfort to their families, give a positive advice instead of despair and disintegration. That is the domain of paliative medicine. An older term is hospice care, but it is no longer suitable.

(more…)

According to the old Chinese proverb when the ruler of the underworld’s daughter falls sick he sends his servants out to find the doctor who is followed by the least ghosts. The one with the fewest ghosts is the best doctor as when patients die, their ghosts haunt the doctor. Over the course of the twentieth century China witnessed some of the most devastating humane tragedies, both during the Second World War and in its aftermath, with the ascent of Mao and his imposition of the Cultural Revolution. The ghosts of the dead follow not the doctors but the politicians. Despite the worst excesses of Maoist practices, novel approaches to the development of a health system emerged, including that of the Barefoot Doctor. After the war China had a large poor rural population that lacked access to Western health care, whose suffering was compounded by the recent ravages of war and food shortages. Into this mix came the Barefoot Doctor – a minimally trained health care worker who had access to the most remote populations.

The effectiveness of Barefoot Doctors is, and continues to be, much debated. A combination of poor statistics, confounding factors and conflicting political ideologies make it hard for a clear picture to emerge. Though quantitative evidence may be lacking, Barefoot Doctors have influenced many other health movements in developing and deprived communities and they were also one of the main inspirations behind the Alma-Ata declaration in 1978[1]. The declaration of Alma-Ata is particularly important because of the infusion of medicine, human rights and public health that were enshrined within its framework. Its contents can be divided into two sections: the principle themes that it enshrines, and public health interventions that it considers essential[2].

• Principal themes

o The importance of equity

o The need for community participation

o The need for a multi-sectoral approach to health problems

o The need for effective planning

o The importance of integrated referral systems

o An emphasis on health-promotional activities

o The crucial role of suitably trained human resources

o The importance of international cooperation

• Essential health interventions

o Education concerning prevailing health problems

o Promotion of food supply and proper nutrition

o Adequate supply of safe water and basic sanitation

o Maternal and child health care, including family planning

o Immunisation against major infectious diseases

o Prevention and control of locally endemic diseases

o Appropriate treatment of common diseases and injuries

o Provision of essential drugs

After the Second World War few developing nations were meeting these ambitions. In 1949, China was a country where the life expectancy was only 35 years. The main causes of death where from infectious disease and malnutrition[3]. By the 1970s, China’s life expectancy was approaching 60 years[4]. Clearly something had changed.

The Need for Another Way

In the late 1940s Dr Chen Zi Qian of the Dingxian health centre calculated that an average person in the rural community could afford to pay 10 cents a year for medical services[5]. At a time when a day’s stay in hospital would cost US$3, modern medicine was beyond the reach of an ordinary worker. Such a situation is made all the more poignant by the fact that 70% of mortality was caused by easily preventable disease⁵. Infant mortality in pre-revolutionary China was at 160/1000 live births, 34,000 died of cholera a year (although this figure is likely to be a gross under-estimation) and tuberculosis caused between 10-15% of annual mortality[6].

Medical care in China before the revolution was sparse. In a country of 540 million people there were only 10,000 doctors trained in Western medicine (though there existed 500,000 trained in traditional medicine)⁷. Additionally most of the doctors were situated in the cities to serve the urban elite whereas 80% of the general population resided in the countryside[7]. The transformation of China’s health care would require a new solution.

The Work and Impact of the Barefoot Doctor

The poor have always been served less well by the medical profession. In England physicians tended to practise only within the circles of the rich, those that could not afford a doctor used the services of the barber-surgeons. With Mao’s proclamation of taking health to the countryside, the Barefoot Doctor was created. The Barefoot Doctors get their name from working part time in rice paddy fields without shoes. Over time their health responsibilities increased and they were re-branded into paramedics or rural doctors[8].

Upon their inception Barefoot Doctors were given just five months of training (though this was later to be increased). According to Dr Joshua Horn, an English physician who migrated to be part of the people’s revolution and was involved in the training of Barefoot Doctors, the trainees studied anatomy and physiology and were introduced to pathology and bacteriology. Practical skills were taught early and, according to the Maoist mantra of learning through work, the trainees shadowed doctors and held their own pre-assessment clinics. The teaching focused on common diseases that were likely to be encountered and they learned the use and formulary of 40 drugs. Their studies were not just confined to the Western school of medicine – they also had to learn 50 acupuncture points[9]. There were also illustrations of common herbs and their uses in the manual that the Barefoot Doctors were provided with[10]. More than just treating disease, a large part of the work of Barefoot Doctors was preventative. In her account of her time as a peasant doctor, Li Qunying describes of how the first thing she would do upon entering a village would be purify the well water[11] and Dr Horn gives several examples of the public health measures undertaken by the local Barefoot Doctors.

Public health and promotion

Assessing the impact that Barefoot Doctors had is hard. Few statistics exist and the accounts that emerge tend to be heavily influenced by political bias. While there were a number of significant achievements within the public health arena, there were also some notable failures. For example, Mao’s initial campaign against the four pests had variable success. Whilst the fight against rats, flies and mosquitoes had improved the health situation, the battle against sparrows may have inadvertently precipitated a famine in the following year by allowing plagues of locusts to ravage crops unchecked[12]. The campaign against the snails (not initially regarded as one of the four pests) was altogether more of a triumph.

Schistosomiasis affected millions of people in China. The “disease causes its ill effects when larval forms of a parasites are released by freshwater snails which then go on to penetrate the skin of people” bathing in the water. Schistosomiasis can damage the bladder, ureters, kidneys, intestine, liver, spleen and abdominal blood vessels[13]. To prevent the disease the snails had to be completely eliminated from the river banks. Such an implausible task was given credence by Mao’s parable of the man who removed the mountains; the tale tells of an old man whose view was blocked by an enormous mountain, so he, with the help of his two sons began to scrape the mountain away. A passer by remarked at the implausibility of the task to which he replied “when I die my sons will carry on, when they die there will be grandsons…and so on till infinity. High as they are the mountains can never grow higher. Every bit we dig away will make them that much lower. Why can’t we clear them away?6” The snails were eradicated from the river banks through a combination of peasants wielding flame throwers and the systematic combing of the river beds. According to some reports cases of schistosomiasis were reduced from 10 million to 2.4 million with most remaining cases being mild[14].

Syphilis was another disease where great strides were made. Before the revolution it was very prevalent and much of it was undiagnosed. A questionnaire was drawn up and given to the villagers. After much education and coercion the questionnaires were filled in and patients started to arrive. Barefoot Doctors carried out the necessary blood work to confirm the diagnosis (only one in twenty patients turned out to have syphilis) and they were then treated. The slightly biased Dr Horn estimated that in some districts 90% of all syphilis sufferers were being detected[15]. Parallels with the HIV epidemic in modern day China can be seen not only in the scale of undiagnosed sufferers but also in the solution that government provides. Entitled “Four Frees and One Care” the government policy is to give free ARVs, free counselling, free drugs to prevent maternal transmission, free schooling for AIDS orphans and care in the form of economic assistance to those affected by AIDS[16]. Whilst the reality on the ground may yet prove different to the political promises, the official line seems to embrace the principle of medicine as a means of social justice.

Preventative work (including health education and family planning) accounted for only 10% of the Barefoot Doctor’s time8. The majority of their time was spent in outpatient consultation (46%). Study and administration took up 10% and home visits took up a further 22% of their time⁸. The most common complaint faced by the Barefoot Doctor was the common cold (10%). Abdominal and musculoskeletal pains came next (9 and 8% respectively)[17]. In theory Barefoot Doctors were trained to deal with 70% of the population’s medical need18. Mobile medical teams (groups of doctors from urban hospitals doing tours of duty in the countryside) were the first port of call for referral from the Barefoot Doctors. The next level of care was the hospital, although this was often an impractical solution due to the distances involved in travelling there.

At its peak the Barefoot Doctor programme had almost two million[18] trained health workers out in the fields. Rural Chinese are however now suffering. With the failure of the Cultural Revolution, the Barefoot Doctor programme declined. This was due to the changing urban/rural demographics and the fact that the Barefoot Doctors carried some of the negative stigma that came with the Cultural Revolution18. Mao’s system of Barefoot Doctors has collapsed and China has gone from a state where nine out of ten people were able to access subsidised health care to a situation where 90% of people are now uninsured and out-of-pocket health care costs are rising fast[19]. Even towards the early 1970s when Barefoot Doctors were trained for longer periods and were devoting more time to going on courses the programme was only costing the average worker nine cents a month (average monthly salary at the time was US$30)[20].

China and Beyond

Allowing the rural poor large scale access to health workers was a remarkable step at the time, given all the problems China faced. Barefoot doctors were often able to treat and at other times they served as a useful step in allowing the patients to access secondary health care. Beyond the medical they also had important roles in sanitation, hygiene and public health. But the mantra of the Barefoot Doctors extended beyond Mao’s China Many health development projects now base themselves on using workers from the community to help achieve their aims. That the Barefoot Doctors worked side by side in the rice paddy fields with their potential patients certainly helped them to be accepted and to understand the perspective of the villagers. In Pakistan, Lady Health Workers have been pioneered to great effect to help reduce post-natal depression and infant mortality[21]. Modern day equivalents of Barefoot Doctors appear not just in the field of health but also in other areas of development. The National Institute of Adult Continuing Education (NIACE) has recently launched a scheme of “barefoot workers” who will help improve literacy amongst female ethnic minority groups in the most deprived areas of London. Similar to the health practitioners in China these barefoot workers will consist of women who work with other women of the same ethnicity to support and help endow them with literacy skills[22].

Mao had many faults. It is hard to envisage that China is now better off due to his Cultural Revolution, however it would also be hard to argue against the fact that health care improved dramatically under his rule. Undoubtedly the health of the Chinese would have improved much further were it not for the arbitrary killings of some of their more experienced doctors and forcing skilled medical personnel to work in the fields as farmers. Policies were not planned properly in advance and unintended consequences, as can be seen with the killing of the sparrows, could be devastating. Part of the problem was that Barefoot Doctors were there not only to serve health needs, but also political ones.

To reject Barefoot Doctors simply because they are tainted by the politics of Mao would be unfortunate. Barefoot Doctors are one of the few positive legacies that stem from Mao’s revolution. They embrace the principles of Alma-Ata long before it was written and were one of the inspiring factors behind the declaration[23]. The concept of healthcare needing to be delivered locally and provided for by culturally competent practitioners was ahead of its time. That Barefoot Doctors also provided a developing nation with universal health coverage to all its population, no matter how remote or how deprived, is no less than remarkable.

Acknowledgments
With many thanks to Dr Jeannette Naish for all her help

---

 

[1] Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978

 

[2] G Backman et al, Health systems and the right to health: an assessment of 194 countries, Lancet 2008; 372: 2047–85 (categorisation taken from the article)

 

[3] Bu Explores Use of Posters in Chinese Public Health, National Institute of Health Newslestter, 06/10/06

 

[4] Patterns of literacy in the People’s Republic of China, A Jowett, GeoJournal 1989 Vol 18 No 4

 

[5] S Hillier and J Jewell, The Development of Chinese Health Care 1911-49, p52, Health Care and Traditional Medicine in China 1800-1982,

 

[6] M Liang et al, Chinese Health Care: Determinants of the system, AJPH 1973 Col 63 No 2

 

[7] Health for the Masses: China’s ‘Barefoot Doctors’, National Public Radio, URL: http://www.npr.org/templates/story/story.php?storyId=4990242, Date Accessed: 04/01/09

 

[8] G Long and C Min, The Role of Barefoot Doctors, AJPH 1982 Vol 2 Supplement

 

[9] J Horn, Away With All Pests- p136, the Hamlyn Publishing Group Ltd, 1969

 

[10] A Barefoot Doctors Manual (translation), Running Press, 1977

 

[11] L Qunying, The Doctor Who Was Followed by Ghosts – p217, ECW Press, 2007

 

[12] The Loneliness of the Chinese Birdwatcher, the Economist, 18/12/08

 

[13] WHO Schistosomiasis, URL: http://www.who.int/topics/schistosomiasis/en/, Date accessed: 04/01/08

 

[14] Health for the Masses: China’s ‘Barefoot Doctors’, National Public Radio, URL: http://www.npr.org/templates/story/story.php?storyId=4990242, Date Accessed: 04/01/09

 

[15] J Horn, Away With All Pests- p92, the Hamlyn Publishing Group Ltd, 1969

 

[16] The history of AIDS from 2003-2006, AVERT, URL: http://www.avert.org/aidshistory.htm, Date Accessed: 21/01/09

 

[17] D Mechanic and A Kleinman, Ambulatory Medical Care in the People’s Republic of China, AJPH 1980 Vol 70 No 1

 

[18] S Hillier and J Jewell, The Cultural Revolution and after – p129, Health Care and Traditional Medicine in China 1800-1982

 

[19] China’s collapsing health care, the Economist, 19/08/04

 

[20] The Prescriptions of Chairman Mao, Time Magazine, 10/01/72

 

[21] Mother and Child, URL: http://www.wellcome.ac.uk/News/2004/Features/WTD006153.htm, Date Accessed: 04/01/08

 

[22] A Woman’s Place, NAICE, 2008

 

[23] To promote the spirit of Alma Ata, conditions are better than ever, People’s Health Movement, URL: http://www.phmovement.org/cms/en/node/934, Date Accessed: 04/01/09

Diane Wu reflects on her summer in Bosnia-Herzegovina.

The bus is destined for another area of town, but I’m getting off at Brcko. The bus rides an N-shaped route from Sarajevo north into Croatia and winds through much of Bosnia’s hilly terrain in the northern part of the Federation. Everyone is sleeping. Some poorly-oiled section of the bus frame squeaks as we round the turns. A cell phone rings. The bus attendant makes a clinking noise as he counts his change. It dawns on me that everything I own is either bouncing across Bosnia on a bus or creeping across North America with Canada Post. It’s a bit surreal.

The topography looks like bubble-wrap – hills are everywhere, blanked by a layer of fluffy-looking trees. Frequently, we see hillsides covered by a shock of brick-coloured houses. Children walk to school. A woman threshes some grass while sheep graze the landscape; the scene is almost bucolic enough to make you forget that anything bad had ever happened here. (more…)

Ashley Neils writes on her experience with the Maasai in Tanzania.

I’ve always loved running. But running with a Maasai warrior changes everything. In fact, being in Africa changes everything. It has certainly changed me.

It is often difficult for people in developed countries to fully comprehend the depth of poverty that grasps many people in developing countries. The majority of Americans are not worried about losing shelter, food, and water. For Africans, these basic needs are not guaranteed. Making it through the day is a struggle. (more…)

Joshua Schulman-Marcus writes on the challenges and opportunities of working in a hospital in Queens, New York. 

A Colombian carpenter with a forearm laceration. A young African-American woman with bedbug bites and a heart murmur of unknown etiology. This patient is from Ecuador, the one in the next bed grew up in Bangladesh. In the corner is a patient who had colonic tuberculosis when she was a child in Uttar Pradesh, while in the trauma bay the woman who fell on the street speaks only Greek (we don’t have Greek translators today). Another waiting patient thinks in Korean, and stutters that the discharge from his back lesion looks like tofu.

The panoply of origins is not just among the patients. My current attending physician is originally from Goa, the surgical consultant trained in China, and the medicine resident in Cairo. Many of the nurses are from various Caribbean islands, though others are from the Philippines and Russia. The clerk is a Korean-American woman and the friendly janitor was born in Mexico (I think). I am originally from the suburbs of New York, but I speak a reasonable Spanish and Hebrew as well. We are nominally a like-minded team of professionals, but at times cultural friction flares. For some of us were originally trained in health systems emphasizing hierarchy, while others learned in more egalitarian settings.

After a year of global health research in Boston, these chaotic emergency room vignettes have been my “welcome home” to New York. They happened at the Elmhurst Hospital Center, a large public hospital in an ultra-diverse neighborhood of Queens. Most tourists to New York never make it out to Queens, a borough with few parallels in the United States. Almost half the borough’s population is foreign born, with every continent amply represented. This immigrant melange, many of whom are poor or uninsured, presents to Elmhurst’s overcrowded emergency department.

The communication challenges of providing quality health care at Elmhurst are formidable. All of the hospital signs are in English and Spanish, and some are also in Chinese, Russian, and Hindi. Although many of us health providers are familiar with medical Spanish, I am sure that we frequently miss nuances or explain ideas poorly. Speakers of other languages are less fortunate; an occasionally available translation phone can provide only so much help. The consequent reliance on relatives to translate diminishes the privacy and personal autonomy afforded to patients.  Sometimes, a communication gap delays a diagnosis or results in an unnecessary admission.

Most of the patients present with common diagnoses. At Elmhurst, though, one’s differential must also include the disease burdens of various developing countries.  Patients frequently travel to their home countries or live with recently arrived relatives. It is not uncommon to see malaria, typhoid, or tuberculosis along with diabetes, pneumonia, and urinary tract infections. A comprehensive mindset is important, but also one mindful of resource constraints and the relative poverty of the patients.

In several ways, I find that my experience at Elmhurst mirrors the challenges and opportunities presented to medical students interested in global health. Enthusiastic about providing health care to the marginalized, we travel to clinics in distant countries. We see a sea of faces rushing by, and we often struggle to communicate across vast disparities in culture, language, and background. Sometimes we succeed, and other times we are left speechless. We are unlikely to see our patients again or develop a longitudinal relationship, as few students remain in one location for a very long while. This remains true if we look to careers in humanitarian relief or medical NGOs. In the end, the situation is not so different than working in an emergency ward.

On the other hand, it is invigorating to serve the marginalized with the best of medical knowledge and technology. As at Elmhurst, to be effective in global health requires a flexible approach, knowledge of the systems that sustain poverty, and a belief that the right to health transcends language or citizenship. In working to alleviate suffering among the destitute or marginalized, one becomes a more thorough practitioner and appreciator of humanity.

For a native New Yorker like me, though, Elmhurst presents a rare opportunity. It is a setting where I can have a sustained global health career without the difficulties of long-term relocation or the inadequacies of sporadic medical tourism. I can strive to provide the longitudinal doctor-patient relationship that is the backbone of a “preferential option for the poor.” I can work to be a better communicator, witness, and advocate for the marginalized of developing countries and of my city. And it’s only a short subway ride away.

Joshua Schulman-Marcus, 4th year medical student at Mount Sinai School of Medicine, New York, USA

jschumar@gmail.com