This year eerily similar stories of tragedy have filled the newspapers. A man loses significant amounts of money because of the current financial crisis and shoots himself. A father is unable to support his family, so he shoots them and then kills himself. Some of these individuals have previous psychological issues but many do not. There is a positive correlation between economic recession and suicide rates. Decreased funding for social services may make it difficult for those who have lost jobs and insurance coverage to receive help if they need it. The National Suicide Prevention Lifeline phone calls increased to 50,000 a month in 2008, about 35% higher than the previous year. Suicide not only affects individuals directly involved in the act, but also their families and the community at large. In the United States, one person kills themselves every 15.8 minutes and it is estimated that at least six individuals are intimately affected by each suicide [1].

The 2008 Supreme Court declaration affirming the right of individuals to keep and bear arms (District of Columbia v. Heller) only aggravated the situation by encouraging higher firearm ownership rates [2]. 55.4% of all firearm-related deaths in the United States are due to suicide and there is a direct correlation between probability of suicide and firearm accessibility. In the first year after the purchase of a handgun, suicide is the leading cause of death among handgun purchasers [3]. Gun owners in America think that if they confront armed intruders with the weapon it will scare them away. Households where a firearm is kept are five times more likely to experience a suicide than those that are gun-free [4]. A gun kept at home is 11 times more likely to be used to commit or attempt a suicide than to be used in self-defence [5].

In extensive studies conducted by Killias [6], significant correlations were found between gun ownership and gun-related suicide and homicide rates. He found no indication that suicidal individuals will turn to knives or other lethal means when guns are not present. Widespread gun ownership was not found to reduce the likelihood of fatal events committed with other means. It is uncertain if the higher suicide rates of gun owning countries are due to overall increased violence or to the increased risk of fatality with a firearm (WHO statistics tally deaths only, not attempts).

In Britain, the simple change from coal gas to natural gas in the 1970s was extremely successful in reducing the suicide rate. Coal gas in a closed space (”Sticking one’s head in the oven”) was deadly in minutes. People did not use other methods to take their lives and the suicide rate dropped dramatically. They could not act as impulsively as before. If the method took more time, the violent impulse dissipated. It has also been documented that of all the people from 1937 to 1971 who planned to jump off San Francisco’s Golden Gate Bridge but were thwarted, only 6 percent went on to kill themselves [8].

More than 90% of suicide attempts using guns are successful, compared to the success rates of jumping from high places (34%) or drug overdose (2%) [7]. Of the 32,637 suicides in the United States in the year 2005, 17,002 of these deaths involved firearms – over 52% [2]. Many of those whose suicide attempt is unsuccessful are later grateful for a second chance at life. Unfortunately, with firearms, the success rate is too high for most to have a second chance. Ironically, those that kill themselves with firearms have a lower history of long term psychological issues – depression, bipolar disorder, schizophrenia, previous suicide attempts- than those who die by less deadly methods. There is a good chance that these folks would go on to live productive, happy lives if the suicide attempt failed. But with guns, the attempt is usually fatal.

Some of the solutions or suggestions to reduce the rate of suicides by firearm (and hence the overall suicide rate) are simple and relatively easy to implement. The ideal of course would be to remove guns from households; the next best thing would be to make sure guns are locked up securely and stored away from ammunition. Shooting oneself is an impulsive act and putting time between the person and the act can make the difference between life and death. Another option is of course, gun regulation including extensive background checks and a waiting period when purchasing a firearm. Supporters of gun rights are not convinced by the research that has been done and by the evidence that has been found. But how much time will we allow ourselves to wait and how many lives will be lost before we take any steps to curb gun ownership rates?

Shaheen Lakhan is currently Executive Director of the Global Neuroscience Initiative Foundation based in Los Angeles, California. Elissa Hamlat is a GNIF Research
Assistant.
slakhan(at)gnif.org

References

1. McIntosh JL. USA suicide 2006: Official final data. Washington, DC: American Association of Suicidology. 2009. Available at http://www.suicidology.org

2. Kung HC, Hoyert DL, Xu J, Murphy SL. Deaths: Final Data for 2005. CDC National Vital Statistics Reports. 2008; 56(10). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf

3. Wintemute GJ, Parham CA, et al. Mortality among recent purchasers of handguns. The New England Journal of Medicine, 1999; 341:1583-1589.

4. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. The association between the purchase of a handgun and homicide and suicide. American Journal of Public Health, 1997; 87(6):975.

5. Kellermann AL, Somes G, Rivara FP, Lee RK, Banton JG. Injuries and deaths due to firearms in the home. The Journal of Trauma. 1998; 45(2)263-267.

6. Killias M. “Gun ownership, suicide and homicide: an international perspective.” In, Understanding Crime and Experiences of Crime and Crime Control, del Frate, A., Zvekic, U. and van Dijk, J.J.M. (Eds.). UNICRI Publication No. 49. Rome: UNICRI. 1993. Available at http://www.unicri.it/wwk/publications/books/series/understanding/19_GUN_OWNERSHIP.pdf

7. Miller M, Azrael D, Hemenway D. The epidemiology of case fatality rates for suicide in the northeast. Annals of Emergency Medicine. 2004; 43(6):723-730.

8. Anderson S. (2007, July 6) The Urge to End It All. The New York Times. Available at http://www.nytimes.com/2008/07/06/magazine/06suicide-t.html

Andrey Ostrovsky tells us how lessons learned from healthcare on an international level can be applied to local healthcare systems.  

International Health has gained significant momentum in the past few years, making it one of the trendiest avenues of medical practice (1). As the machine of global medicine quickly accelerates toward improving health conditions abroad, domestic healthcare issues must not be allowed to fade from view. Overcoming international and domestic healthcare obstacles may pose different challenges, but the approaches to overcoming these challenges are not mutually exclusive. Several lessons from attempts to administer health systems in developing countries are applicable to all health systems. It is time to apply the lessons learned abroad to problems faced at home. The following overview of lessons from developing countries is meant to serve two functions: 1: to remind doctors practicing abroad that they have unique expertise which is much needed at home, and 2: to encourage health system administrators to think outside the box – and the borders – when addressing local healthcare issues.

Donor Fund Allocation 

The first lesson pertains to one of the most salient issues in health system strengthening, which is the proper allocation of funding. This issue is not a matter of how much money is being pledged to aid developing countries, but rather where the money is going. Earmarked funding for AIDS alone or TB alone or Malaria alone creates several parallel programs that stifle health system integration. For example, in Uganda, international agencies’ funding of HIV and AIDS programs exceeds the entire Ugandan government’s health budget (2). Consequently, these programs paralyze the local governments by congesting too few avenues with too much money. Instead, funds should traverse through an integrated network of thoroughfares which would lead to general health system strengthening. The lesson here is to efficiently address the major diseases simultaneously by bolstering the ministry of health as a whole and using it as a common foundation upon which individual disease interventions can be constructed.

 This lesson is sadly ignored in developed countries like the United States. While several states have made valiant efforts to create universal access to healthcare, the majority are lagging. Much of the contention, as usual, comes down to funding. Politicians argue that it is too expensive to fund programs that provide universal access, so they concede to fund piecemeal interventions that only address solitary problems even though universal access can actually be less expensive. For example, in the state of Maryland, a beautifully crafted proposal for universal healthcare access is projected to cost $3.1 billion per year, whereas the current annual budget for healthcare exceeds $22 billion (3,4). Unfortunately, political and financial pressures will likely defeat the fiscally sound Maryland proposal and perpetuate a disjointed health system.

Role of Economics in Health Outcomes

Whether seeking to reform the health system of a small state or an entire country, the issue of money inevitably accompanies the issue of medicine. Another key lesson from developing countries is that socioeconomic determinants are linked to health outcomes (5). To elucidate that link, the World Health Organization (WHO) used data from developing countries to create a conceptual framework for understanding the complex relationship between health and its various determinants. The framework encompasses the direct and indirect effects of the national economy, household economies and health-related sectors on population-level and individual health (6). The WHO builds on this framework and codifies a key lesson by highlighting that the health of poor populations can be improved through economic interventions.

 Some developed countries lose sight of the reciprocal relationship between the economy and health outcomes. In a time when financial stability of even the wealthiest nations is in jeopardy, policy makers are reluctant to commit significant funds toward healthcare. What must be realized from lessons from abroad is that stabilization of the economy is contingent upon a stable healthcare system. For example, if the current fiscal constraints cause a flood of people to lose their jobs, they would ultimately be unable to pay for their medical care. Subsequently, large medical bills would go unpaid, hospitals would accrue debt, and providers would not be paid for their services. This scenario could quickly snowball into the healthcare system equivalent of the U.S. banking crisis. By saving old jobs and/or creating new jobs that provide a means to pay for healthcare, the economy can be used to bolster population health. Healthier people would make more productive workers and in turn boast the economy. Fortunately, the Obama administration quickly realized this association by making healthcare a top priority in times of extreme financial turmoil. This and other developed nations should not think of investment in healthcare and the economy as two separate, high-priced bank notes, but rather as different sides of the same frugal coin.

Vertical and Horizontal Health System Integration 

 Experiences in developing countries teach that providing adequate care in resource poor settings requires more than just economic stimulation; it also requires vertical and horizontal integration of the health system. In a poorly integrated system, top-down administration, such as country-wide ministry of health mandates, has limitations because the needs and resources of each locality may be different. To address this problem, a 2005 WHO consortium of government officials and NGOs from developing countries recommended that local actors need a place at the national policy table to give appropriate perspective, offer education, and provide access to care (7). This recommendation affirms that health system information and interventions must be vertically integrated from the bottom-up as well as from the top-down to properly address all parties’ healthcare needs. Additionally, experts in health system administration in low-income countries suggest that collaboration between parties at the same health system level would promote better provision of services (8). Thus, horizontal integration through side-to-side communication between various health sectors can augment vertical integration by avoiding unnecessary bureaucratic obstacles or duplication of services.

 The tenets of vertical and horizontal integration can similarly be applied to developed countries to improve access to care. In the state of Maryland, a single county did just that. Healthy Howard is an effort spear-headed by the former Baltimore City health commissioner, Peter Bielenson, that created universal access to healthcare for all residents in Howard County (9). The initiative utilizes vertical integration by having county officials advocate for local healthcare needs by soliciting state funding. Additionally, various parallel services offered through the health commission, private industry, tertiary hospitals, and health interest groups are horizontally integrated into a net that covers almost every constituent’s health needs. Although Healthy Howard is an example of successful health system integration leading to universal access to care in a developed nation, it is the exception rather than the rule.

Messaging

The success of Healthy Howard would not have been possible without the right messaging. Messaging comes in two flavors. Positive messaging, also known as framing, is taking true messages and making them known to the public through accurate education.  Negative messaging, or spin, is conveying messages in a misleading way that obscures the true content of the message. In developing countries, where there is so much misunderstanding about health issues, health interventions are futile without the right messaging.

 The importance of messaging in developing countries is highlighted in an HIV prevention study of over 600 men in Ghana. The data show that perception of condom efficacy strongly influences actual condom use (10). In other words, health information must be properly framed in order to influence behavior. Fortunately, positive messaging has been quite effective. In Brazil, an advertisement campaign focusing on safe sex was developed in response to statements by some religious leaders questioning the efficacy of condoms in preventing HIV infection. The campaign effectively educated the public and influenced condom use in the country (11). Unfortunately, messaging is effective even if it is negative. For example, the Bush administration’s President’s Emergency Plan for AIDS Relief (PEPFAR) mandate overemphasized abstinence and faithfulness to the exclusion of condom prevention strategies. The mandate’s misguided focus resulted in “major funds going to religious groups with little or no experience in either AIDS programs or Africa more broadly” (12). Consequently, the spin from these groups regarding HIV prevention is largely skewed. Studies show that abstinence-only programs run by such groups have “high rates of failure in terms of both infection and other adverse outcomes such as unintended pregnancy” (13). Messaging campaigns in developing countries provide the lesson that public perception is a determinant of public health.

 Messaging falls under the purview of Public Relations (PR), and in developed countries this is a booming industry. However, PR has not been fully utilized by the medical establishment to appropriately frame the major healthcare issues. Medicine has spread beyond the walls of hospitals into the arenas of law, business, and even entertainment; it’s time for medicine to start doing PR. In a society saturated with spin on healthcare, medicine must recruit PR experts to influence policy makers and the public to embrace productive changes to the current health system.

Conclusion

Using these lessons, health systems in developed countries can be bolstered by refining fund allocation, incorporating healthcare with the economy, integrating health sectors, and employing effective messaging. In an era where communication with the opposite end of the world is no longer limited by mileage but rather by band-width, sharing ideas between developing and developed countries is easier than ever. With globalization at a peak, physicians with global health experience are perfectly suited to make significant contributions both at home and abroad. The medical establishment should encourage more physicians to engage in international health in order to continue generating transposable lessons in health system strengthening.

Andrey Ostrovsky is a third year medical student at the Boston University School of Medicine.
andrey@bu.edu

References

 (1) Ostrovsky A. Global health is “the new pink”. Lancet Student 2008. Available at http://www.thelancetstudent.com/2008/11/19/global-health-is-%e2%80%9cthe-new-pink%e2%80%9d/

 (2) England R. The dangers of disease specific programmes in developing countries. 2007. BMJ, 335 (7619):565. 

(3) Maryland Citizens’ Health Initiative. “Health care for All” Plan Proposal. 2008. Page 1. Available at <http://www.healthcareforall.com/parameters/healthcareforall/uploads/dl/2008_HCFA_Plan/MD_HCFA_Plan_2008-11-12.pdf>

(4) Wilson DE. State Health Care Expenditures. Maryland Health Care Commission. 2004. Page 9. Available at <http://mhcc.maryland.gov/health_care_expenditures/shea02/shea2002.pdf>

 (5) Mosely WH & Chen LC. An analytical framework for the study of child survival in developing countries. Population and Developmental Review. 1984, 10: supp25-45.

 (6) Woodward D; Drager N; Beaglehole R; & Lipson D. Globalization and health: a framework for analysis and action. 2001. Bull World Health Organ, 79(9). 

 (7) Travis P & Bennett S. The “Montreaux Challenge”: Making health systems work: Background paper. WHO. 2005. Available at  http://www.who.int/management/background_1.pdf

 (8) Bennett S, Hanson K, Kadama P, & Montagu D. Working with the non-state sector to achieve public health goals: Background Paper. WHO. 2006. Available at  http://www.who.int/management/background.pdf

 (9) Howard County, MD Government. Healthy Howard Access Plan. Healthy Howard. Available at http://www.howardcountymd.gov/Health/HealthMain/Health_HHAccessPlan.htm.

 (10) Adhi WK & Alexander CS. Determinants of condom use to prevent HIV infection among youth in Ghana. J Adol Health. 1999;24:63-72.

 (11) Okie S. Fighting HIV — Lessons from Brazil. NEJM. 2006:354(19);1977-1981

(12) Dietrich J. The Politics of PEPFAR: The President’s Emergency Plan for AIDS Relief. Ethics and Int Affairs. 2007;21(3):277-292.

(13) Center for Health and Gender Equity, Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis, March 2004, p. 8. Available at http://www.comminit.com/en/node/181474/36.

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…)

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…)

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…)

Jonny Currie writes on the need for change in the world order and the importance of students in making this happen. 

Whoever said student apathy was rife? Look around you and I feel confident that you will find otherwise. For a phrase that has been commonly attached to students recently, (1) we are failing to acknowledge the rising tide of enthusiasm amongst the youth of today on a diverse range of issues. Students facing their universities and their spurious environmental policies; (2) students tackling an unjust availability of medicines in resource-poor countries; (3) I am heartened, not cynical, that the youth of today will be the change of the tomorrow. (more…)

Justin Healy writes on the inextricable links between medicine and politics. 

Taken in photographic isolation, the art of medicine, whether the inoculation of a child or the replacement of a heart valve, would appear to be the most apolitical of all acts.  In the context of a medical consultation there should be no consideration given to any agenda other than the benefit of the patient.  Matters of colour, faith, political opinions and even criminality are not supposed to interfere with the doctor’s ultimate responsibility to the sick person before them.  This is not merely blind idealism; from Hippocrates to the GMC doctors have been exhorted to look first to the well-being of their patients. (1, 2)  For a doctor to place a political agenda above the health of their patient would be crass, insulting and positively dangerous.

And yet, the arts of medicine and politics have grown to be inextricably linked.  A rickety scaffold of political machinations that supports the platonic ideal of the doctor-patient alliance.  Though politics may have no place in a medical consultation; it most certainly determines who built the consulting room, how the doctor is paid and what treatments the patient may get.  It is a blissful ignorance that declares medicine independent of the dark arts of politics. (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…)

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…)

Mark Prince writes on the extremes of healthcare quality in South Africa. 

The standard of healthcare can vary considerably from one country to another and sometimes from one region to another. However, in Cape Town there are vast inequalities present in the standard of healthcare provided within different parts of the same city. During my clinical elective internship in 2007 I worked in three hospitals within Cape Town and saw for myself the inequity, racial discrepancies and politics that underpin the current healthcare service. (more…)