VOLUME 18 ISSUE 1
Doctors for Human Rights
www.doctorsforhumanrights.org Company Number 3792515 Charity Number 1078420
DHR’s sustained campaign supporting refused asylum seekers’ health rights in UK Over the last 16 months DHR has focused upon informing and engaging
INSIDE THIS ISSUE:
the British medical profession over the denial of refused asylum seekers’ rights to the highest attainable standard of health. Not only does the issue
Page 1 - DHR’s campaign, Bernie Hamilton’s Archive
have intrinsic merit as an important contemporary concern, but it also serves as a vehicle with which to educate doctors on health rights to an extent that previously proved elusive. article continues on page 2
Page 2 - DHR turns the UK Government down
Page 3. - IFHHRO’s Zimbabwe conference; DHR strategy; DHR, the Lancet and the arms fair trade
Pages 4 to 8 - Letter from Nigeria by Helen Bygrave
Page 8 - AGM and elections
Albert Sloman Library
Bernie Hamilton Archive at Essex University Although it had been anticipated for some while that Bernie Hamilton’s papers would go to Essex University, where the UN Special Rapporteur on the right to the highest attainable standard of health holds the chair as Professor of Human Rights, it was not until February 2007 that a librarian from Essex’s Albert Sloman Library collected the 25 crates and 6 boxes. In thanking Mrs Hamilton, the librarian praised the clarity with which Bernie had classified his papers and the neat way in which
HEALTH IS CONTINGENT UPON RESPECT FOR HUMAN RIGHTS
they were filed. “I have no doubt“ he said “that the Bernie Hamilton Archive will prove a major asset to students and scholars of human rights for many years to come. A list of the documents will eventually be added to the library catalogue.” Special rapporteur Paul Hunt also wrote to say how pleased he was to have the papers adding "Bernie was a good colleague for some years. We worked together in Geneva and London and Essex. I benefited greatly from his advice over the years”- article continues on page 2
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DHR’s sustained campaign continued from page one Bernie’s papers go the Essex continued
In the September 29th BMJ, DHR’s second letter criticising the negative effect of the BMA’s stubborn silence over the violation of refused asylum seekers access to secondary care, was published. This was the fourth in a unique quartet of DHR articles - the others being the original July 2006 BMJ editorial that explained the legal basis of their violation of human rights, the first BMJ letter of May 2007 and the Lancet Comment of August 2007.
Nigel Rodley, former UN Special Rapporteur on Torture, who also works at Essex University, sent his own comment “I can only echo Paul's sentiments. I thought of Bernie as both colleague and friend. It was always good when our paths crossed here or abroad. It is some real comfort to know that we will be able to house his valuable collection and archive in the Library."
This series of publications dealing with a single issue from one source relies on DHR’s leading position on health rights in the UK. The government now plans to publish new rules on access to healthcare for refused asylum seekers, which many expect to limit free access to primary care as well as hospitals.
DHR refusal of Government request vindicated In July 2006 DHR was asked by the UK government to send a team to Libya to assess the human rights training requirements of an organisation run by Saif Qadhafi - one of President Qadhafi’s sons.
their release in July 2007 the Palestinian doctor and nurses have described how they were all tortured during their imprisonment. DHR concluded that given that the Qadhafi Development Foundation was led by one of the Head of state’s sons, the organisation would need to have convincingly demonstrated its independence from Government influence before DHR could consider participating in a process that might end with the Foundation being responsible for protecting returnees from being tortured.
In an effort to forcibly send more Libyan asylum seekers and detainees home, the Government intended to allow the Qadhafi Development Foundation to monitor their human rights. In October 2005, the government signed a Saif Qadhafi deal with Libya known as a memorandum of understanding, under which Colonel Gaddafi's government pledged not to mistreat anyone deported to Tripoli from the UK. The Convention against Torture and the European Convention on Human Rights, both prohibit the UK from deporting people to regimes where they may face persecution or torture
In April 2007 the Special Immigration Appeals Commission, the body that deals with deportation of terror suspects, supported DHR’s conclusion. The Commission's chairman, Mr Justice Ouseley, said that Libyan men faced a real risk of mistreatment. "There is also real risk that a trial of the appellants would amount to a complete denial of a fair trial," he added. The government said its own investigations into the Qadhafi Development Foundation convinced officials that it was independent of the regime and capable of monitoring the welfare of returnees.
Libya had a poor record on torture, with people being held incommunicado and tortured by the Internal Security Agency. Only two years previously six health professionals had been sentenced to death by firing squad after being accused of deliberately infecting 426 children with the HIV virus. Since
The two appellants solicitors commented: "It was common ground between the government and [our clients] that political opponents of the Gaddafi regime are reasonably likely to be tortured or otherwise ill-treated if returned to Libya.
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DHR strategy DHR’s current grand strategy is
Zimbabwe conference 2007
threefold:- to encourage the medical
This October the annual
profession to adopt health rights as an
International Federation of Health
ethos; to campaign for the creation of
and Human Rights Organisations’s
Crimes against Humanity for economic,
health and human rights conference takes place in Harare Zimbabwe.
social and cultural rights (as opposed to
DHR chair, Peter Hall will be
already existing Crimes against Humanity
for civil and political rights) - that includes the right to the highest attainable
DHR was the third organisation to join the Federation in 1990. There
standard of health; and to redevelop and
are now 15 member organisations
update DHR’s medicine and human rights
and 8 observer organisations
modular course in order to facilitate
including Amnesty International,
education for doctors and medical
WHO, the WMA and the ICRC
DHR’s contribution to ending Reed Elsevier’s involvememt in arms fairs. In March 2007 The Lancet published a DHR letter that criticised Reed Elsevier - the Lancet’s publisher - for its involvement in arms fairs. The Guardian picked up on the controversy, writing - A second letter, from Peter Hall of Doctors for Human Rights, reads: "The Lancet, as the foremost medical journal on global health issues, engages with all threats to human longevity or mental and physical wellbeing ... it is thus shocking to hear that the publisher ... continues to align itself so supportively with the arms trade." Happily within three months Reed Elsevier announced its withdrawal from taking part in organising arms fairs. The BMJ News section recorded that Peter Hall, chairman of Doctors for Human Rights, condemned Reed Elsevier for refusing to take any action earlier, in the face of two years' criticism and despite the fact that Spearhead Exhibitions accounted for only 0.5% of the group's turnover. "Reed Elsevier stubbornly held onto a blinkered perspective that the promotion of the arms industry was a profitable venture," Dr Hall told the BMJ. "Reed Elsevier's change in policy is not only a triumph for those who participated in the campaign to persuade Reed Elsevier of its error in promoting arms trade but also for the integrity of the medical and scientific world." 3 HEALTH IS CONTINGENT UPON RESPECT FOR HUMAN RIGHTS
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Letter from Nigeria by Dr Helen Bygrave former DHR executive committee member
Although I resigned from the DHR committee in December 2005 to work for Medecins sans Frontieres (MSF) in Nigeria, I have not forgotten their work, all be it, I have been a little more detached from its daily goings on. So better late than never I am putting down some reflections on my last year in Nigeria which has given me a lot of food for thought when considering health and human rights.
provides water for three hours at a time, twice a day.
Nigeria, a country of 131 million – they say every fourth African is Nigerian – is a boiling pot of tribal (373 ethnic groups), political, multinational oil dealing and of course health challenges. Since the end of military rule in 1999, this has been the longest period of civilian government in the country’s history. But despite this, Nigeria’s human rights record and apparent reluctance to help the poorest of its citizens does not bode well for a calm approach to the 2007 elections.
Aside from the ongoing oil related conflict there are a number of other key issues that raise concerns regarding respect for human rights. Ongoing ethnic and religious divisions fuel conflict and in February more than 100 were killed and thousands displaced following religious riots in the northeastern city of Maiduguri. Sharia law is in force in 12 of Nigeria’s 36 states, handing out sentences of floggings, amputations and death. A number of forced evictions have occurred, making thousands of people homeless without adequate notice, compensation or alternative accommodation. The state officials carrying out the forced evictions reportedly used tear gas and beat residents.
When thinking of human rights and Nigeria the mind immediately turns to the Ken Saro Wira story and the plight of the Ogoni people in the Delta region. His execution in 1995 led to outrage across the world and highlighted the suffering of one of the many marginalised ethnic groups whose land has been turned into a wasteland by the oil spills and gas flares that have become a daily occurrence for these communities. Certainly during 2006 a growing number of violent clashes were seen including the abduction of expatriate oil workers. In one of the worlds largest oil producing countries it does seem somewhat ironic that the communities in the oil producing regions have electricity for two hours a day from a generator installed at the villagers’ cost and Chevron Nigeria only HEALTH IS CONTINGENT UPON RESPECT FOR HUMAN RIGHTS
The voice of women and children are muffled in the eyes of the state. Exploitation of children by enforced labour and child trafficking remains a serious problem. Violence against women is widespread and not brought to light due to discriminatory laws and practices. Women are raped and subjected to other forms of sexual violence by government agents as 4
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well as partners, employers and others. In some communities, female genital mutilation and forced marriages continue to be practised. On a more positive note last year the Nigerian Government did decide to hand over the former Liberian president, Charles Taylor to face charges in the UN backed war crimes court in Sierra Leone
days when ARVs cost $100 dollars a month and a handful of patients delved into their pockets for them. Now after successful battles with the drug companies, which MSF spearheaded, generics are available, Global fund money is being distributed and in December 2005 the Nigerian Government announced that ARVs would be available free throughout the country. What this means on the ground is somewhat different and certainly I did not witness a huge amount of direct Nigerian money being put into the pot.
My major concern last year, working for the international NGO Medecins Sans Frontieres, was healthcare and specifically the HIV epidemic. Reflecting on my experiences in the context of article 12 - the right to “the highest attainable standard of physical and mental health” brings the words of these documents into stark reality. In 2006 life expectancy in Nigeria stands at 45, and child mortality 196/ 1000. There are three million people living with HIV/AIDS and an estimated 520,000 needing antiretrovirals (ARVs) right now, making Nigeria the third largest caseload after South Africa and India. In 2006 there are now 75 ARV sites treating in total approximately 73000 patients a huge shortfall in terms of need.
The majority of agencies working on HIV in Lagos State are funded through USAID / PEPFAR ( presidents emergency plan for AIDS relief ). Many are providing a fantastic service but some interesting caveats start to appear when you look more closely. For example ARVs are free but not treatment for opportunistic infections (OIs). So if a patient was admitted with cryptococcal meningitis and couldn’t afford the amphotericin and life long fluconazole then the prognosis was not looking quite as rosy. MSF was very clear that not only should we be looking at free ARVs but a comprehensive care package including OI treatment. In addition the American funded programmes are all tied to the “big pharma” companies - part of the PEPFAR deal negotiated by Mr Bush. This means that dollar for dollar many more patients could be receiving treatment if the American funded projects were allowed to use WHO prequalified generics as we were doing in our MSF clinic. Also many of the generic formulations come as fixed dose combinations allowing the necessary triple therapy to be given in one tablet twice day. This is not so with the Big Pharma preparations hence inflicting higher pill burdens on the patients and making adherence more difficult.
My project was based in Lagos, a unique city in many ways, exposing me to all the good and bad sides Nigeria had to offer. MSF has been running a HIV service based in a state run Hospital in Lagos Island for approximately 2 years now and by the end of 2006 had almost 2000 patients on treatment.
All this being said ARVs are getting out there and most certainly are making a difference. It has been one of the most rewarding pharmacological interventions I have made in my career. I can’t count the number of times a patient
In 2001 I worked in Uganda .These were the HEALTH IS CONTINGENT UPON RESPECT FOR HUMAN RIGHTS
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caught my eye in clinic who I may not have seen for 3-4 months and you really would not recognise them. But now after programmes have been running for two to three years new challenges are starting to be faced. The need for cheaper second line regimes, the question of when is it prudent to change a patients drugs when investigations may be limited, questions of minimising the development of drug resistance and also working with the Ministry of Health and government to ensure dome degree of sustainability for these clinics.
is still raising its ugly head. In the hospital our team kept telling me that things had improved as two years ago HIV positive patients would be put in a bed at the end of the ward and left to lie in their own excretions. After ongoing training and by having one of our MSF nurses actively involved on the wards the fear of touching someone with HIV is reducing but I was still asked by one student nurse as I was examining a patient’s chest whether I was afraid of getting HIV from the patient and would I like some gloves.
Working in the context of our HIV project within the general hospital also raised some difficult questions. The daily reality of the work brought home many of the stark realities of being sick in a country with a faltering state health service. This was particularly evident when walking through the wards and casualty. The MSF patients received all free care from our doctors and pharmacy but unfortunately this was not the case for other patients needing treatment and admission. All programmes have to have distinct borders and criteria but having to actively see patients that because they were not HIV positive have to suffer was heartbreaking. If you did not pay your 1000 naira (approx $10) entrance charge for casualty you simply did not come in, whatever your complaint. After that the cost of tests, drugs and basic necessities such as gloves, swabs, needles all had to be individually bought. There were situations where the patient may have the drug but if the relatives had not bought the gloves the nurse would not give the IV injection.
One of the hardest issues however for me was observing the attitude of the doctors. During training sessions they would produce the most brilliant academic responses but on the ground I could see very little evidence of any diagnostic thought process or evidence of responsibility for patient care. Whether working in a chronically under resourced environment can be given as an excuse I don’t know, but when malaria, TB and HIV treatment is free in your hospital surely it is a simple duty of the doctor to ensure if there is suspicion of these diseases that the patient is investigated and receives the appropriate treatment. A study released last year by Physicians for Human Rights “Nigeria: Access to Health Care for People Living With AIDS,” showed that a disturbing number of Nigerian health professionals engaged in discriminatory behaviours towards people living with HIV/AIDS (PLWAs) practising against both international and Nigerian codes of ethics. The study represents the experiences of nearly 4,500 health care professionals in four states who serve a combined population of approximately 17.8 million people.
Life on the wards Stigma and discrimination towards those living with HIV/AIDS is well known to worsen the spread and the impact of the epidemic. Although awareness is improving listening to patients stories of how they had been forced to give up work and the daily attitudes of staff in the hospital made it clearly evident that stigma
Some striking figures give a picture of what HIV provision in Nigeria is up against. Ten percent of respondents admitted refusing to care for or admit people living with AIDS to a hospital. Practices such as testing without consent and release of confidential information were 6
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found to be common occurrences. Twelve percent of professionals said that treatment of opportunistic infections in HIV/AIDS patients wastes resources and seven percent agreed that treating someone with HIV/AIDS is a waste of precious resources. Not a fantastic outlook for those who are at their most vulnerable entering the overstretched health system. The majority also cited lack of training on HIV/AIDS something that MSF and other local NGOs were trying to combat. But fundamentally there has to be a change in attitude to the individual patient. At this point, after maybe portraying a somewhat negative opinion of the care provided, I have to actively thank the fantastic team of Nigerian National Staff that actually made our clinic run and who indeed showed huge commitment and compassion for our patients. It is there but still has to seep through to the mainstream. As well as the medical activities in the project we also worked alongside our access campaigner. The team worked with both the local and international media and very closely with a local activist group the Treatment Action Movement (TAM). Two major projects I was involved in were the campaign against Abbot to make available and reduce the cost of the new heat stable Kaletra and in organising a photography exhibition â€œPositive Facesâ€?. MSF has been at the forefront in the battle to reduce the costs of first line ARVS and now faces the same challenges for the second line combinations. Kaletra produced by Abbot is a commonly used drug used in theses regimes but the formulation we had available requires refrigeration- something that is extremely difficult in a city where people are without electricity supply for months on end. A new heat stable version had become available in the States but did not have marketing approval for developing countries such as Nigeria and certainly not at the price of the original formulation. MSF took this battle on and with much media attention from the BBC, Reuters and the like, Abbot was persuaded to
change their policy. By mid 2006 we had the new heat stable version in the project. I believe Nigeria was the first African country to use this drug and will certainly set precedents for Abbot to move forward with other countries desperately in need. Theses first hand experiences of how active campaigning and use of the media could really push things forward was an incredibly rewarding experience to be part of. Heat stable Kaletra reaches Nigeria So what next. At present the state health system is certainly starting to burst at the seams in its attempt to start treatment for all those queuing outside their doors. way the health system is currently structured it will not be able to sustain and continue to provide quality care for all those PLWA. The next step is to start to implement HIV care at the community level both in an attempt to destigmatise and also reach the increasing numbers of people needing treatment. This would also mean taking on board the concept of nurse led models of care something that Nigeria has not until now embraced. Our team had ! begun an assessment looking at how this could be done in a slum area within Lagos which obviously in itself poses a number of additional challenges. I feel undoubtedly the integration of HIV into primary care is the way forward for effective ARV provision but unfortunately at present in Nigeria the state run primary health facilities, if existing at all, are overstretched and understaffed at best. So a grand proposal to take HIV care into the community will only succeed if there is first a serious sign of government support and funding put into the current primary health care system. My year in Lagos brought out all sorts of emotions regarding the reality of the Right to Health Letter from Nigeria continued on page 8
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The election of DHR committee members
including the election of executive committee members
This year DHR continues the election cycle as described in the Newsletter prior to the 2000 AGM.
Saturday 1st December 1 pm at the
This year the ordinary executive committee members will be elected
The Grayston Centre 28 Charles Square London N1 6HT
Members can vote in the Membersâ€™ Ballot by attending the AGM and voting, or by postal vote, arriving at 91 Harlech Rd, Abbots Langley WD5 OBE not later than three days prior to the AGM. Nominees names must arrive not later than three days prior to the AGM to include: a. written notice of a members nomination signed by one other member of DHR b. a written agreement to serve in such office if appointed signed by the nominated member elected
Letter from Nigeria continued
that has been at the forefront of DHRs work over the last few years. In the U.K. where the right to health is starting to be used to legislate in the courts I often found myself wishing the patients could use the power of the law to sue some of the doctors for downright medical negligence â€“ with no grounds to blame lack of resources. Maybe including some human rights teaching in the Nigerian medical curriculum, something we have been trying to pursue here, would alter the sense of duty and responsibilities of the clinicians. I feel happy though leaving the project knowing there are some extraordinary people committed to take on the ongoing challenge of dealing with the HIV epidemic in Nigeria and making the Government face up to their responsibilities. For me I am now heading to Myanmar (Burma) to be HIV advisor to the MSF projects, so a few more health and human rights challenges ahead for me as well.
Dr Helen Bygrave in Geneva
References / Further Reading www.hrw.org Essential Background Overview of human rights issues in Nigeria (Human Rights Watch World Report 2007, 31-122006 www.amnesty.org Amnesty International What you should know- Nigeria www.physiciansforhumanrights.org Nigeria: Access to Healthcare for people living with HIVand AIDS www.msf.org 8 HEALTH IS CONTINGENT UPON RESPECT FOR HUMAN RIGHTS