In the line of fire-Medical practice in times of war ISSUE 3
january 2007 1
by sunita DE SOUSA
by gail brenda cross
Mind over War
mind over war
BY KARL RUHL
BY DR ANDREW PERRY
interview with PHILIPPE TANGUY BOOK REVIEW
BY KARL RUHL
3-4 NEWS REVIEW BY JACQUI MCDONNELL 4
links & resources
BY KATHRYN LOON
ar is a battle of physical and technological might. Armed forces attack each other to push a political regime whether it be totalitarianism or puppet democracy. Regardless of the political drama, the civilians of invaded countries are the most brutally harmed. Whilst the big governments waging war will undoubtedly ride through these troubling times like guntooting cowboys, the citizens of nations in war will continue to be under siege. What these people need might be democracy, but it is so much more than that. Citizens of nations under fire need refuge, food, clean water and healthcare. It is time governments set aside some gun money and put this toward healthcare initiatives such as the refugee social interventions spoken of in this Issue’s Feature Article. Through reading this Issue of Vector, I hope you will understand how doctors can assist such healthcare initiatives and save lives in the line of fire
by Sunita De Sousa,
Editor of Vector
The incidence of frank psychiatric illness does however increase in conflict. Because much of the research is conducted on refugees in post-conflict settings, it is noted that Post Traumatic Stress Disorder (PTSD) and anxiety are the most frequent problems, but depression and somatoform disorders also feature. In fact, 5 million of the 50 million refugees worldwide in 1999 were found to have chronic mental disorders. Another 5 million had psychosocial dysfunction affecting how they lived. The WHO insists that psychological support should be delivered along side the provision of food, water, basic health care, shelter and security. Unfortunately, such psychological interventions are limited by the capacity and training of field workers and resources. In addition, without adequate assessment and understanding of the socio-cultural undercurrents in a particular region, cultural differences can and have been mistaken for psychiatric illness. Collaborating with local non-government agencies and indigenous healers can alleviate this problem and make primary mental health care more sustainable. Here in Australia, we have not been immune to the psychological impact of war. Media accounts of suicide, self harm and depression amongst asylum seekers manifest the disgraceful conditions in detention centers from Woomera to Port Headland. The Medical Journal of Australia recently published data which shows that those granted temporary protection visas had levels of anxiety, PTSD and depression much more severe than those granted permanent asylum. Australia’s policy of mandatory detention for ‘illegal’ refugees and asylum seekers in stark penal like conditions, further deteriorating already traumatised minds, is in breach of the 1951 Refugee Convention to which Australia is a signatory. It is plainly inhumane. As members of the medical community, we must not rest on our laurels and remain ignorant of the moral and social consequences of war. The inevitable violation of human rights that follows from conflict, regardless of whose war it is, has an undeniable physical and psychological impact. Whether we advocate for the end of war altogether or fight for the right of refugees and asylum seekers to be treated with dignity, we need to mobilise as a profession to protect and prevent state-sponsored oppression here on our seemingly safe shores and beyond.
ars often destroy the fabric of society by generating terror to control populations. The trauma of forced killings, witnessed massacres, torture, sexual violence, detention and uprooting remain in personal and collective memories long after peace agreements and repatriation. Conflict needlessly inflicts its wrath on the most vulnerable and on the psyche of both combatants and civilians. As Kofi Annan leaves his office this month, he lamented that the situation in Iraq is much worse than civil war. Besides the conflict-related death and disease, the violence in the streets of Baghdad is symptomatic of the aggregated psychosocial trauma suffered by Iraqis. After three wars, routine human rights abuses under Sadam’s dictatorship and the abominable failed attempt to rebuild Iraq, it is no surprise that the Iraqi Ministry for Health records high rates of depression, anxiety and somatisation. Besides frank mental illness, family violence such as spouse and child abuse in these tense times also contributes significantly to the burden of disease. The distress most people experience in times of conflict is not in fact psychopathology, but a normal reaction to extraordinarily violent events. The use of psychiatric assessments and therapy in refugee camps is therefore often redundant. The World Health Organisation (WHO) accordingly advises aid groups to institute social interventions such as reuniting families, developing cultural spaces and restarting schools as a means of bolstering psychological defenses. People who operate as a community in cooperative solidarity are more likely to recover than an individual in a dingy room with a volunteer counselor.
by Gail Brenda Cross
“Empowering medical students in creating sustainable health improvements in developing communities”
[ email@example.com ]
In the line of fire-Medical practice in times of war page 2
édecins Sans Frontières (MSF), is an organisation which aims to respond to medical emergencies no matter where they occur. I spoke with Philippe Tanguy, Head of Communications for MSF Australia, about its philosophy of providing medical aid to those who need it regardless of politics, development agendas, conflict and natural disasters. As I discovered, the organisation views the doctor-patient relationship as paramount and this occasionally brings it into conflict with other non-government organisations. As Head of Communications, Philippe is a direct extension of MSF’s field activities. He explained how bearing witness -or témoignage- to the suffering of those under MSF’s care was an important part of its charter, though in a strictly medical sense. For example, the organisation has been vocal in denouncing sexual violence
as a strategic tool of war in the Democratic Republic of Congo (DRC). There and in other states, militias storm villages and subjugate the population sexually rather than with weaponry. Even under supposedly democratic regimes, sexual terrorism ensures that humiliated men, women and children will vote the ‘right’ way. MSF does not denounce these atrocities because they are human rights abuses or because such a situation is grossly unjust. They do so because their patients are suffering. In war, the sexually abused can die because of HIV infection or through obstetric complications of unwanted pregnancies. MSF aims to care for the whole patient, accordingly taking the psychological impacts of rape and trauma very seriously as well. To many it seems surprising to hear that MSF refused to provide evidence in the form of patient medical records to a Human
Rights Tribunal in Tanzania. The reason for MSF’s behaviour is simple: it would breach patient confidentiality. “We’re interested in keeping these people alive. They’ve trusted us by admitting they’ve been raped and we’re not going to break that trust, even for the sake of tremendous human rights abuses”. The concern of MSF is that the goals of human rights activism and economic development do not necessarily have as their immediate priority the health of the people. “A patient is a patient, regardless of who he is… We do not deal with the politics of the situation or distinguish between sides”. MSF aims to remain strictly neutral because this is the essence of the doctor-patient relationship. In an Australian emergency department, the doctor does not ask the patient to adopt certain political views or to sign a petition supporting a local development program as a prerequisite to providing care –so it is with MSF. Even when the organisation is not wanted by one side - though this is rare - Philippe concluded that MSF “pays no notice whatsoever, because we consider every human being to have a right to health and it’s on that basis that we cross borders”. MSF has been working in the DRC for 25 years, which, for an organisation strictly concerned with acute emergencies, speaks volumes about both the severity of the crisis and the dedication of the organisation. MSF Australia, in conjunction with the New York VII photo agency, is currently raising awareness about the humanitarian crisis in the DRC through a photographic exhibition. The photos are being exhibited in many major centres around the country. For more information about the exhibition and MSF’s work in the DRC, go to http://www.msf.org.au/minisites/drc_ exhibition/index.shtml.
by Karl Ruhl
packing hundreds of requested cannulas, catheters, boxes of gloves, stethoscopes, ECG machines as well as surgical and anaesthetic equipment into pallets and freight containers then sent to 14 hospitals located in India, Cambodia, Bolivia and Vanuatu to name but a few countries. Global HOME, University of Sydney
Campus International Health Groups
or up to date, comprehensive information on each group, head to the IHN website at www.ihealthnet.net. Medical Students’ Aid Project, University of NSW
his has been another highly successful year for MSAP. Every year, MSAP collects donated equipment and raises funds to purchase medications to send targeted aid along with medical students undertaking elective placements in developing countries. This year, MSAP had an incredible launch attended by a large number of the UNSW medical community demonstrating just how committed the student body is to this project! Packing day, as the name implies, involved
lobal Home has had a great year since its establishment in April. The Global Home team recently hosted its final event for the year, a Health Advocacy Forum. The event was a great success with up to 80 people in attendance including many new faces. The keynote speaker was Dr Nick Coatsworth from MSF who shared his experiences from the field. Organisers also used the opportunity to promote the upcoming IFMSA General Assembly and to share the projects of other international health groups around Australia. Ignite, Monash University
t has been an exciting time over the last few months for Ignite. In conjunction with rural health club at Monash, Ignite held a Central-American themed trivia night, raising funds and awareness of the many health issues faced by this part of the world. In conjunction with the rural health club at Monash, Ignite also ran the Burnet series of talks which proved particularly thought provoking, with the most recent session being on the topic of HIV/AIDS. The organisation should be particularly congratulated on its inaugural ‘Communities in Need’ photo exhibition held in October. It was a great success with a display of over 100 photos taken by students on attachments in developing communities.
Vector magazine firstname.lastname@example.org Wakefield Press http://www.wakefieldpress.com.au
he ANU Clown Doctors project was a huge success and hopes to repeat the program next year. It took place at their main teaching hospital and the event received publicity in the weekend papers. There was fantastic feedback about the Children’s Day with up to 50 people in attendance including medical students as well as nursing and academic staff. Vector
t was exciting for the Vector team and the IHN to receive so much positive feedback about our first two issues of Vector! A big thankyou to all of you who have contributed to this magazine with insightful articles, photographs and illustrations. We are currently starting a writing competition, thanks to sponsorship from Wakefield Press, to provide you with even more incentive to put pen to paper! See the advertisement above for more information. International Federation of Medical Students’Associations (IFMSA) General Assembly
he March 2007 General Assembly of the IFMSA is being hosted by AMSA in Perth and Mandurah. The IFMSA facilitates medical student exchanges and undertakes international projects related to reproductive health, AIDS, human rights, poverty, starvation and medical education. The IHN will be represented among the Australian delegation.
Compiled by Karl Ruhl
IHN P u b l i c i t y O f f i c e r
In the line of fire-Medical practice in times of war
he new Australian Medical Students’ Association-International Health Network (AMSA-IHN) committee has been working hard since the Developing World Conference to help all medical students pursuing interests in international health. We are excited to see a growing number of campus groups dedicated to this aspect of medicine and encourage groups to support each other’s projects.
For more information, please see:
Lending a Hand: the Aid Issue
Prizes for Prose
All who email in will be notified of future writing opportunities. Entries following the callouts will then be judged on the basis of quality of written expression and currency or relevance of themes. Authors of the winning entries will be published in Vector and shall receive one of the newly-released books from Wakefield Press. Email us today and get ready to write!
so we’re giving you the chance to put pen to paper about international health with some tasty incentives to boot. -a Vector writing competition Wakefield Press has a v e generously donated a selection of books detailing the extraordinary stories of medicos s o m e t h i n g whose careers in international health changed to say about the lives of themselves, their loved ones and global health their patients. i s s u e s ? So, if you: Passionate a r e s t u d y i n g m e d i c i n e a t a n about human Australian university; rights or fresh want to help educate and empower off the plane from a life-changing elective? your fellow students; At Vector, we recognise that med love to write and can do so well; students’ literary talents aren’t given sufficient then please email your expression of recognition by multiple choice answer sheets, interest to email@example.com!
In the line of fire-Medical practice in times of war
3continued from page 3
As in many African countries, it is the cultural norms and lack of women’s rights in Malawi which have fuelled the HIV epidemic: child brides and polygamy are not uncommon and a woman would never ask her husband to wear a condom for fear of repercussions. Without the much needed advocacy from people such as Madonna, orphanages will forever be the fate of the children of Malawi. On the other hand, is she diminishing the value of human life by showing the world that you can purchase anything at the right price? A quandary indeed, you decide.
Democratic Republic of the Congo: A Country Holds its Breath for Election Results
iolence, street rioting, looting and burning buildings -this was the picture of the DRC after the national elections held on the 30th of October. The results will be announced on the 19th of November. The Congolese have suffered years of violence and civil unrest. 355, 000 people are living in appalling conditions in neighbouring countries as refugees and many more are living in even worse conditions as internally displaced persons. Twenty-five million people took part in their nation’s future by voting for political stability with one leader, not many waring factions. They voted for a better future for their children, for enough food to feed their families and for access to healthcare and education. The presidential election in Congo is the final stage of a peace process and transition to democratic rule as set forth in the Global and Inclusive Agreement of 2003 which was to end a decade of violence that killed more than four-million people and destabilized the region. Both political sides have signed a commitment to renounce violence and guarantee the security of the losing party. Do we believe the situation can change overnight?
Postscript: As results were announced, it was shown that the stability of the DRC is not able
to change overnight. The current DRC president, Joseph Kabila had garnered 58 percent of the vote, but his opposition Jean-Pierre Bemba rejected this win. The DRC Supreme Court is yet to announce the final outcome and the people of the DRC continue to hold their breaths.
Extensively Drug Resistant Tuberculosis: emerging epidemic in developing communities
ast month, the Lancet reported that certain strains of tuberculosis (TB) resistant to both first-line and second-line drugs are currently threatening the success of many TB programs as well as HIV treatment programs around the world. Extensively drug resistant tuberculosis (XDR-TB) is not a new problem; practitioners working in Eastern European and Central Asian countries have known its existence for some time. What is disquieting about recent outbreaks, however, is that it is taking place in South Africa, where there is an increased risk of rapid infection amongst HIV-positive people. The World Health Organisation (WHO) has been called upon to provide newer drugs to patients by working with regulatory agencies and pharmaceutical companies to ensure fast-tracked clinical development and availability of new drugs. Time will tell how many will receive the required treatment but how many will die before the red tape is slashed?
WHO is the next Director General? - New directions for the World Health Organisation
r Margaret Chan of China has been elected the next Director-General of the WHO. Dr Chan was previously the WHO Assistant Director-General for Communicable Diseases and the Representative of the Director-General for Pandemic Influenza. In her acceptance speech, she told the World Health Assembly she wanted to be judged by the impact WHO’s work has on the people of Africa and especially on women across the globe. She is aware of the challenges that lay
ahead, citing the most tragic diseases as “lack of resources and too little political commitment.” Dr Chan especially praised the people around the world who deliver health care. “The true heroes these days are the health workers with their healing, caring ethic. They are determined to save lives and relieve suffering, and they work with impressive dedication, often under difficult conditions. The world needs many, many more of them.” Dr Chan obtained her Medical Degree from the University of Western Ontario in Canada and also has a degree in public health from the National University of Singapore. For more information on Dr Chan go to: http://www.who.int/mediacentre/news/ releases/2006/pr66/en/index.html
Bush’s ‘War on Terror’ Continues but Iraqis Still Cry for Peace
elebratory gunfire swept across parts of Baghdad and other Iraqi cities on the 5th of November as Saddam Hussein and two former top Iraqi officials were sentenced to death for crimes against humanity. Are all Iraqis happy with this result? ‘Riverbend,’ an Iraqi woman in her late 20’s, expresses what many are feeling: “This is Bush’s final card. The elections came and went and a group of extremists and thieves were put into power… The constitution which seems to have drowned in the river of Iraqi blood since its elections has been forgotten….Reconstruction is an aspiration from another lifetime: I swear we no longer want buildings and bridges, security and an undivided Iraq are more than enough…. Iraq has not been this bad in decades. The occupation is a failure. The various proAmerican, pro-Iranian Iraqi governments are failures…..Is it really time to turn Saddam into a martyr?” The resignation of one of the main architects of the U.S.-led occupation, Donald Rumsfeld, on the 8th of November may have brought some satisfaction to the Iraqi people, but how long will it be before food supplies, healthcare and peace can make their way back into Iraq?
by Jacqui McDonnell
Links and Resources
or more information on the psychological impact of war, check out:
Bruntdland, BH. (2006). Mental Health of refugees, internally displaced persons and other populations affected by conflict. WHO: Geneva. Available from: <www.who.int/hac/techguidance/ pht/mental_health_refugees/en/> Enduring Effects of War: health in Iraq. (2004). Published by MedACT UK. Available from: <http://www.mapw.org.au/ Iraq/iraq-index.html>
or more information about the work of MSF in the Democratic Republic of Congo and other regions, visit: <www.msf.org/msfinternational/countries/africa/ democraticrepublicofcongo/index.cfm>
or regular and comprehensive updates on health and humanitarian emergencies, don’t go past: AlertNet <www.alertnet.org>—regularly updated information on aid and development around the world.
Médecins Sans Frontières (MSF) <www.msf.org> —offers assistance to populations in distress, to victims of natural or manmade disasters and to victims of armed conflict, without discrimination and irrespective of race, religion, creed or political affiliation. Global Health Reporting <GlobalHealthReporting.org> —information on key international health issues. Eldis Gateway to Development <www.eldis.org> comprehensive information on all the major health and development issues, with thousands of resource documents available for free.
inally: AMSA is hosting the next International Federation of Medical Students’ Associations General Assembly in Mandurah, Western Australia next March. To learn more about the IFMSA, head to <www.ifmsa.org/>. For more information on registration, go to <www.mm2007.org/>.
Compiled by Kathryn Loon with thanks to IGNITE Editor Design & Layout Sunita De Sousa Vanessa Fitzgerald firstname.lastname@example.org email@example.com
© Antonin Kratochvil / VII
Médecins Sans Frontières (MSF) Australia presents
DEMOCRATIC REPUBLIC OF CONGO:
FORGOTTEN WAR “Offers a glimpse of hope through the people’s resilience and the hand of humanitarian assistance. We’re compelled to bear witness...”
“Will send you back out into the world with a changed perspective. A rare and powerful insight into ongoing human disaster.”
New York Downtown Express
A unique photo exhibition from VII photo agency, New York, now on its Australian tour 2006-2007 · Brisbane 12 July-6 August · Townsville 15-27 August · Melbourne 26 September-15 October
· Canberra 23 October-5 November · Adelaide 11-28 November · Hobart 7-18 December
· Sydney 6-28 January · Perth 9-25 February · Shepparton 8-18 March
For more information go to www.msf.org.au
Entry is free