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Global Medicine edition

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December 2008 – official IFMSA-NL magazine on

global health – distributed free of charge – visit www.globalmedicine.nl

Global Medicine

Clinical trials in developing countries 6  neglected disease Dengue in Brazil 10  article Orphans in Rwanda 16  photo gallery Safe motherhood 18 article Undocumented migrants 20  article Gender inequality in Southern Sudan 26  studentBMJ article Hinduism: Life and death 29 article


Editorial I had never met Simon when I sent him an email to ask for his comments on the article about orphans in his country (page 16). He told me the story of his life in return. From the first day my relatives were killed in front of the French troops who were naming themselves peace keepers, I started hating everyone including myself. Rwanda has child led families of more than 50 children in just a single family and the international community still stands aside doing nothing. It is clear that we need to be more realistic on this issue. Do you feel what I am trying to say in these inadequate words? If so, what can you do to help, as someone who seems to be interested in this issue? One thing I can do, Simon, is to create more awareness about these issues. This is why we make Global Medicine. We present the diversity of health matters that exist outside our safe country borders. Issues that every future doctor should know about, but our faculties don’t teach us. Global Medicine is a magazine for medical students, by medical students. We invite you to share your experiences and submit your eye opening article, elective report or column. Visit our website and contact the editors to learn how you can contribute to our next issue. This edition of Global Medicine is created by a fresh editorial board and has a brand new layout and website. On behalf of Simon and all others who have made this edition possible: thank you for your interest in worldwide medicine. Enjoy reading. Emmaline Brouwer Editor in Chief

Clin

Uneth

Photo g

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Undocumente

Barriers to the univ

Gender inequality in Sou

Striking disclosures and encouragi

Global Medicine is the official IFMSA-NL magazine and is published three times a year. Contact us at editor@globalmedicine.nl. Full references for all articles available online at www.globalmedicine.nl. Find the small print on page 35.


News

GM Global health news

nical trials in developing countries

hical practice or a product of necessity?

Clinical trials in developing countries Dengue: a neglected disease

6 10

Column by Loes Magnin

18

Medicine brings global health into vision

Hunger season in Malawi

15

Article

The Rwandan struggle on child welfare

16

Photo Gallery

Safe motherhood

20

versal right to health and health care

uthern Sudan

Article

Article

gallery: Safe motherhood

ed migrants

6

4

IFMSA-NL article

Undocumented migrants

ing perspectives from a forgotten society

20

Column

Blue tulip

26

18

24

Article

Gender inequality in Southern Sudan

26

StudentBMJ article

Hinduism: Life and death

29

GMMix

Studying in... Lisbon Book reviews

34 35


GM News on global health IMPACT OF THE GLOBAL FINANCIAL AND ECONOMIC CRISIS ON HEALTH Summary of the statement by WHO DirectorGeneral Dr Margaret Chan, 12 November 2008: “The current financial crisis comes at a time when commitment to global health has never been higher. It is not yet clear what the crisis will mean for low-income and emerging economies, but many predictions are highly pessimistic. It is essential to counter this period of economic downturn by increasing investment in health and the social sector. There are several strong reasons supporting this line of action. Inevitably, it is the most vulnerable who suffer the most; the poor, the marginalized, children, women, disabled, the elderly, and those with chronic illness. Second, investment in the social sectors is investment in human capital.

Healthy human capital is the foundation of economic productivity and can accelerate recovery towards economic stability. Third, equitable distribution of health care is a critical contributor to social cohesion. Social cohesion is the best protection against social unrest, nationally and internationally. Lastly, robust health systems are essential to maintain surveillance and response capacity in the face of pandemic threats. I am calling on all governments and political leaders to maintain their efforts to strengthen and improve the performance of their health systems, to protect the health of the people of the world, and in particular of those most fragile, in face of the present financial and economic crisis.”

Obama & Global Health President-elect of America, Barack Obama, pledges to double US aid for promoting global health by 2012. He plans extra investments of $1 billion over five years to fight HIV/AIDS in Southeast Asia and Eastern Europe and supports the rights of sovereign nations to access quality-assured lowcost generic medication to meet their pressing public health needs. He also pledges to increase funding for better sanitation and universal primary education. Critics question the (financial) feasibility of Obama’s plans. Also, the strong HIV/AIDS focus is disapproved of and global health advocates urge the US government to widen the focus.

2009 International Year of Human Rights Learning On 10 December 2008, the International Year of Human Rights Learning sets off, to be devoted to activities to broaden and deepen human rights learning. It aims to enhance the promotion and protection of all human rights and fundamental freedoms, including the right to development.

Firm introduces flavoured anti-malaria drug In Nigeria a special tasty flavoured drug is introduced: Actimax®. It is a combination of antimalarial Artemether and Lumefantrine and is available in the flavours banana, orange and raspberry.


NEWS

No obliged consent leads to more HIV testing in high risk groups

Condom use dependent on age difference between partners

Populations at highest risk for HIV infection face multiple barriers to HIV testing. A hospital in San Francisco eliminated the required written patient consent for testing and the amount of tests increased with 67%, especially among males, homeless and uninsured patients. More people were diagnosed HIV+ than before the policy change.

Researchers investigated condom use among adolescents in four African countries. They found that only 20-45% of the adolescents are using a condom, most often in Ghana, the least in Malawi. Age difference between partners is a major determinant of consistent use of condoms: young men with a 0-4 years younger partner are about 2.5 times more likely to use condoms than those with an age difference of 5-9 years. Other important predictors of consistent condom use are residence, education & exposure to condom demonstration and exposure to media. The authors conclude that education programmes on healthy sexual behaviour are definitely effective in these countries.

Primary health care: now more than ever The 2008 World Health Report focuses on primary health care. “Globalization is putting the social cohesion of many countries under stress, and health systems are clearly not performing as well as they could and as they should. Health systems need to respond better and faster to the challenges of a changing world. Primary Health Care can do that.” Download the full report at http://www. who.int/whr/2008/en/index.html.

Development in research on Mycobacterium ulcerans Mycobacterium ulcerans infection, or Buruli ulcer, is the third most common human mycobacteriosis worldwide. Buruli ulcer is a devastating, necrotizing disease, with a huge social impact. The disease is present in impoverished, humid, tropical, rural areas of Africa, even more frequently than TB and leprosy in some regions. Besides being a disease of the poor, Buruli ulcer is a poverty promoting chronic infectious disease. Portaels et al. have now isolated M. ulcerans from an aquatic insect in Benin, and proved that this insect transmits the pathogen to humans. This finding will have positive consequences for the control of this neglected tropical disease.

References   Obama: Bristol, N. Obama vs McCain on global health. The Lancet 372; 9638, 521-22   Obama: http://www.one.org/blog/2008/11/05/ president-elect-barack-obama   Burden of Disease: http://www.who.int/mediacentre/news/notes/2008/np11/en/index.html   Financial crisis: http://www.who.int/mediacentre/ news/statements/2008/s12/en/   Year of HRL: http://www.un.org/dpi/ngosection/ conference/pdfs/HR_Resolution.pdf   HIV testing: Nicola M. Zetola et al. PLoS ONE. Feb. 2008   Anti-malaria drug: http://www.thisdayonline.com, September 2008

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Clinical trials in developing countries Unethical practice or a product of necessity? Emmaline Brouwer Kano, Nigeria, early 1996. An outbreak of cerebral spinal meningitis kills 15 000. Médecins sans Frontières (MSF, Doctors without Borders) are the first NGO to arrive and work around the clock to treat the over 115 000 infected. The epidemic constitutes a severe public health crisis to the Nigerian government. A few weeks after the onset of the outbreak, Pfizer, the largest pharmaceutical company in the world, sends employees to Nigeria to conduct a clinical trial with the newly developed antibiotic trovafloxacin (Trovan®). Pfizer aims to bring Nigeria a life saving, innovative, less painful and cost effective form of antibiotic that could be used effectively to treat

epidemic meningococcal meningitis, including in children. Almost 200 children are included in the study. Half of them receive trovafloxacin, the others are treated with the ‘best practice medication’, ceftriaxon. At least eleven of the children in the study group die, many others develop mental or physical disorders during or after the treatment. In 2001, the Nigerian federal government starts a lawsuit against Pfizer, claiming $7 billion for the victims and their relatives. The government declares that the authorities did not approve this clinical trial and the patients and their families did not give informed consent before treatment.

$/ Nigeria

144 720 00 inhabitants

1 410

income per year

♂ 48yrs ♀ 49yrs life expectancy

Pfizer denies all accuses. The court case proceeds until today. The Trovan® case has become famous as the illustration of negative consequences of clinical testing in developing countries. Although exact numbers are unknown, it is clear that an increasing part of clinical trials by pharmaceutical companies is conducted in lowincome countries. Large companies such as GlaxoSmithKline, Wyeth and Merck report to perform 29-70% of their trials in ‘non traditional research areas’; scientists estimate this number to be 40% on average for all pharmaceutical trials.

$

3.9%

of GDP for health

/

0.28

doctors/1000 people


ARTICLE

Reasons for testing in developing countries

Informed consent?

The main reason for the companies to choose new locations for their trials is that costs are 10-50% lower than in traditional research areas. Furthermore, less strict (or lack of ) legislation helps research protocols to be easier and earlier accepted. If preparatory procedures take less time, more years for profit making within the patent period remain. Another pull factor is the fact that volunteers for trials are more easily found. This is partly because populations are larger and thus more patients with a certain disease are available. Yet, in many cases participation in a trial is the only chance for a patient to receive any treatment at all, and often the (financial) incentives form an important encouragement. A medical argument for testing in developing countries is that the outcome of research has a higher validity if the subjects of study have received less medication (similar to the one studied) before participating in the trial. Finally, there are high economical benefits for hosting governments, an important incentive to relocate trial venues to their countries. For example, India receives an estimated income of $1.7 billion in 2010, when 2 million Indians are estimated to take part in clinical trials.

Non Governmental Organizations (NGOs) critically follow this transition to trial locations in developing countries. Their main argument against most of the clinical trials is that they are unethical, for they do not comply with the Helsinki Declaration, a document adopted by the World Medical Association stating ethical principles regarding human trials (see box on page 9). One of the concerns is the issue of informed consent. Due to analphabetism, language difficulties and a hierarchic doctor-patient relationship, informed consent is complex to

obtain. Furthermore, poverty and dependency on the offered treatment make informed consent a subjective matter of discussion and question the voluntarism of the participants. Moreover, the Helsinki Declaration states that after the trial ends, the participants should be assured access to the best proven therapy identified by the study. This is often not the case in developing countries and was true for the meningitis outbreak in Kano, Nigeria, too. 15 Social and public health aspects of the debate include the shortages of educated health personnel in developing countries. Working for

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the trials means a large burden on the already heavy workloads of doctors and nurses. On a larger scale, it is often argued that most drugs on trial are developed to combat welfare diseases (as this entails greater profit) and to a lesser extent to combat tropical diseases that local residents mostly suffer from.

Responsibility A large responsibility is with the local medical ethical committees that approve the research protocols. Assessment of these local committees has shown that 25% of the clinical trials in developing countries has had no ethical evaluation at all and that less than a quarter of the ethical committees follow the existing guidelines when reviewing a proposal. If guidelines are in place, there is often a lack of legislation to support them. Large differences between the committees make it easy for pharmaceutical companies to choose the lenient ones to send their protocols to. They should promote responsible behaviour among themselves to comply with international guidelines and regulations. NGOs urge stronger stakeholders to take responsibility in this matter. The European Union and the US Food and Drug Administration (FDA), as drug approving institutions, should help local governments to comply with the Helsinki Declaration. Strict control of medical ethical committees will


ARTICLE

force them to review their protocols critically. Development support (e.g. training of health care workers) could also strengthen local health care systems. Another recent development is an (online) database of clinical trials that are being conducted worldwide. This ensures an easier method of control for NGOs and Western governments, as well as making sure no double research is conducted.

Because of the lower costs, lack of ethical evaluation, guidelines and supporting legislation, it remains attractive for pharmaceutical companies to conduct clinical trials in developing countries. Informed consent procedures that are adhered to are inadequate. Also, patients are often denied the best available care after trial completion. Responsibility for changing this situation is shared by local ethical committees, pharmaceutical companies, NGOs, the EU and the FDA.

Further reading    Pfizer: Trovan fact sheet http://www.pfizer.com/ files/news/trovan_fact_sheet_final.pdf    SOMO: Ethics for Drug Testing in Low and Middle-income Countries    SOMO: Examples of unethical testing    Wemos: “A bitter pill”    WMA: Helsinki Declaration    Nuffield council of bioethics: The ethics of research related to health care in developing countries (2002)

The Helsinki Declaration The World Medical Association (WMA) compiled a document with ethical principles regarding clinical trials on human subjects. The Helsinki Declaration is regarded as the basis of human research ethics for all doctors, researchers and other health care workers worldwide. A summary of relevant paragraphs is listed below. 2. It is the duty of the physician to promote and safeguard the health of the people. 5. The well-being of the human subject should take precedence over the interests of science. 8. Vulnerable research populations require special protection. 13. The protocol for a clinical trial should be reviewed by an independent ethical review committee. 20. Participation in a trial must be voluntary and participants must be informed. 29. A new method should be tested against the best current method. 30. At the conclusion of the study, all trial participants should be assured access to the best proven therapy identified by the study. In developing countries, it is often difficult if not impossible to comply with all guidelines. Therefore, alternatives have been proposed. For example, the Nuffield Council of Bioethics, London, has recommended to test against the best available treatment for a disease in that national public health system.

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Dengue

A neglected disease Machteld Julsing Santa Casa de Misericórdia, Sobral, Ceará, Brazil A mother with her little, visibly ill daughter enters the Emergency Room. The girl is two years old and has been ill for six days with high fever, headaches, backpain and myalgia. When the mother started to think the girl was getting better, the child began to lose weight, accompanied by nausea and vomiting with the strange addition of a very sensitive skin. Physical examination reveals a maculopapular rash on extremities, face and trunk, scattered petechiae on the legs, bleedings of the gingiva, a rapid, weak pulse, hypotension and cyanosis. Abdominal palpation and percussion show hepatomegaly. The girl is lethargic and in a state of shock.

The hospital files show the girl’s history: a year ago she was treated for dengue fever, which resulted in a full recovery. A blood differential is ordered and confirms the doctor’s fear: leukopenia and thrombocytopenia are apparent. Immediately the girl is admitted to the Intensive Care unit and monitored carefully. She is started on oxygen administration and five percent dextrose in Ringer’s lactate intravenous infusion. Treatment against disseminated intravascular coagulation (DIC) is also initiated. After ELISA on IgM the serum shows antibodies against two different types of dengue virus.

$/ Brazil

189 323 000 inhabitants

8 700

income per year

♂ 68yrs ♀ 75yrs life expectancy

Diagnosis: Dengue shock syndrome (DSS) as a result of dengue haemorrhagic fever (DHF) after two sequential infections of different serotypes of dengue virus.

$

7.9%

of GDP for health

/

1.15

doctors/1000 people


Global Medicine presents Neglected Diseases About one billion people in the world are affected by one or more neglected tropical diseases (NTDs). Neglected, because these diseases persist exclusively in the poorest and the most marginalized communities, and have been largely eliminated and thus forgotten in wealthier places. www.who.int/neglected_diseases

This is the first article in a series on neglected diseases. For additional information, check www.globalmedicine.nl.

1 000 000 60

800 000

600 000

40

400 000 20 200 000

0

Pathophysiology Frequently, dengue viral infections are asymptomatic. Symptomatic dengue predominantly occurs in the immunocompromised or non-indigenous. The symptoms include fever, rash, pain in muscles and joints and start abruptly with minor illness for two to four days followed by rapid worsening, after an incubation period of five to ten days. Being infected with one serotype gives a lifelong immunity against that serotype, but merely a small and passing protection against the other ones. A small percentage of patients who have previously been infected by one dengue serotype develop bleeding and

7 -0 00

9 -9 90

20

9

1% (in specialized institutions)

Treated DHF/DSS

3%

Untreated DHF/DSS

50%

Epidemiology People living in infected areas worldwide Endemic countries Annual infections Cases of DHF Child deaths

19

-8 80

9 -7

Mortality rates Dengue fever

19

9

70 19

-6 60 19

55

-5

9

0 19

Two hundred years ago, dengue only sporadically caused an epidemic. It spread from South-East Asia to America, the Pacific Ocean, Africa and the Carribbean. The reason for the spread is the increasing possibilities for travelling. Nowadays dengue is the most important mosquito-transmitted viral disease worldwide. In comparison to five decades ago, the recent incidence multiplied thirtyfold; a very disturbing evaluation. More countries are infected and also the epidemics are massively explosive. For instance in 2007 there was an outbreak in Venezuela, reporting 80 000 cases of dengue, including over 6 000 cases of DHF.

Reported cases of dengue to WHO

Number of countries

There are four types of the dengue virus: DENV-1, -2, -3 and -4. They all belong to the family of the Flaviviridae. The virus is transmitted by the Aedes aegypti mosquito. Aedes aegypti probably has its origin in Egypt. It crossed the Atlantic Ocean from Africa in times of slavery. The name dengue is a derived from the Swahili sentence ki denga pepo, which means it is a sudden overtaking by an evil spirit. It refers to the rapid onset of the disease. This appeared in English literature during a Caribbean outbreak in 1827-28. The first definite clinical report of dengue is attributed to Benjamin Rush in 1789, but the viral aetiology and its mode of transmission via mosquitoes were not established until early 20th century.

ARTICLE

Epidemiology

2.5 billion 100 50 million 500 000 22 000

Data adapted from WHO http://www.who.int/csr/disease/dengue/en/index.html

Cases of dengue

History

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Nepal Hawaii

Sudan

Galapagos Islands

Madagascar - La Réunion

Easter Island

Marcelo Lucena, Brazilian medical student

Yes, dengue, it´s just like you write there. But remember that dengue is an educational problem. To combat the disease we must teach the people to combat the standing water in their homes.

Countries and areas at risk of dengue transmission, data 2008. Red lines indicate the 10°C isotherms (upper line: January, lower line: July). Adapted from WHO.

endothelial leak upon infection with another dengue serotype. This syndrome is termed dengue haemorrhagic fever (DHF) which can result in dengue shock syndrome (DSS) and may cause death.

Transmission Dengue fever is transmitted from human to human or from primate to human by the female Aedes aegypti mosquito. The mosquito lays her eggs in standing water in garbage dumps in inner cities. Clothing provides no protection against Aedes aegypti that bites during daytime, as opposed to the malaria mosquito. The virus circulates in the patient’s blood for two to seven days.

Diagnosis

Prevention

First dengue infection can be diagnosed by the IgM-capture Enzyme-Linked ImmunoSorbant Assay (ELISA). For second infection other serological diagnostic tests are needed as research shows that 28% of the second infections were missed by ELISA. For DHF the blood pressure tourniquet test is used. The test is DHF positive when more than 20 petechiae per square inch appear.

Until today there is no dengue vaccine but research is in progress. Education can inform people about standing water as the source of mosquito multiplication and about how vinegar might be used to destroy the eggs and larvae of the Aedes aegypti.

Treatment Dengue fever is self-limiting and therefore treatment is only needed to reduce symptoms. DHF and DSS are a different story. Patients should be admitted right away. Administration of oxygen, hydration with intravenous sodium solution and treatment against DIC can be life saving.

Further reading   WHO. Dengue Haemorrhagic Fever: early recognition, diagnosis and hospital management. 2006 via www.who.int/csr/disease/dengue/en/index.html   Harrison’s principles of Internal Medicine


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COLUMN

Column

Hunger season, Malawi, South-East Africa Loes Magnin I'm in humid, sticky, somewhat smelly and very sweaty Malawi. People have finished their stocks from last year. The new crops, mainly maize, are growing but they are not ready for consumption yet, meaning food seems within reach but it isn’t. This is a truly tantalising time for the Malawian people. Welcome to the Malawian hunger-season.

There are a couple of other patients here. They are all women; some pregnant, most of them looking very ill. There’s a lady who looks pale, not a good thing for a black African. A lady who I think is in labour. Another woman lies with her head on her lap, she’s not moving at all.

I wonder... how long have they been sitting here? Not only is this season characterized by its lack of food and income, but due to its humidity it is also a high risk time for malaria and cholera. I’m staying with a friend, and I’m waking up to the biggest headache that I ever had. Friend has gone off to work so I force myself to get up and make some food. After only a few bites I start feeling nauseous and the room starts spinning around me. I look at the cold concrete floor of Friend’s house and am overwhelmed by its sudden appeal. It must be so nice to lie on such a cold and hard floor, much better than sitting in this chair. I decide to lie down on the floor, and doze off a little. Friend comes home and is shocked to find me on her floor (I still really like the floor actually). My back hurts, my head hurts, my throat hurts. I feel chilly and even though it’s 35°C here I could really do with a warm sweater. Friend decides to take me to the local medical clinic, but as we arrive there, there is no medical staff. Actually, there’s no staff of any sort. I sit down on a bench, while Friend looks for… well, anybody? Hello?

The clinic has an interesting message for us; all the staff are out for lunch, and as it’s Friday they won’t be coming back until Monday morning. Huh? But what if I actually do have malaria? What about these women here, who are in even more need of help than I am? I’m shocked, annoyed and angry, but I need all my energy for the walk back home. Friend and I head our way to an international health clinic in town. I get tested positive for malaria. I pay for the test, I pay for my pills, I pay the doctor’s fee, I pay the taxi driver who takes us to the clinic, I pay for the phone call to my insurance company to rearrange my flight and two weeks later I am back on my feet again in clean and well organized Amsterdam. Back on my feet because I could afford it. Yet… I can’t help but wonder how those ladies are.

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The Rwandan struggle on child welfare In this article Ilona Dekkers reflects on the current situation of Rwanda, in the aftermath of an internationally recognized devastating genocide. Her main focus is on child welfare. In 2007 she was part of the European youth delegation, which accompanied the European Commissioner for Development and Humanitarian Aid, Louis Michel, during an educational visit to Rwanda.

Ilona Dekkers The legacy of the genocide On April 6th 1994, the assassination of the Rwandan Hutu president Habyarimana lead to the genocide. Hutu extremists wanted their revenge and began to systematically murder Tutsi and moderate Hutu. After a 100 day massacre killing a million Rwandans, many children were left orphaned. A decline in health services was the result of this. The Rwandan government faced a lot of challenges in rebuilding the country and this struggle continues until today. The most important purpose of the government is to restore the economy to pre-genocide levels. The transformation of an agricultural

subsistence to a knowledge based economy, together with improvement of education, infrastructure and investment in companies could reduce poverty. One of the goals of the Rwandan government is to prioritize child welfare, especially for orphans.

Health care The new health sector “Strategic Plan 20052009” aims to reduce poverty and to improve health. Rwanda has a community based health insurance scheme, which provides treatment access even to the poorest. The government is committed to fight against HIV/AIDS, tuberculosis and children’s diseases.

Orphans in Rwanda According to statistics, Rwanda has about one million orphans. These children’s parents were either killed in the genocide or died from AIDS. Many of these orphans live in households that are run by children, and suffer from depression and other health problems. Most orphans feel severely marginalized from their communities and are vulnerable to abuse and exploitation. The government and international organizations try to provide the orphans with health care and education; however the majority are still in need of more help. A new National Policy on Orphans and Vulnerable Children is now


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being implemented throughout the country. This policy will provide more protection to these children. School fees also have been eliminated, allowing more Rwandese children to receive the basic primary school education. A catch-up programme has been introduced to help children who previously were not able to attend school.

Nkundabana! During our journey we visited the Nkundabana project. This community-based project is organized by CARE International. Nkundabana means “I love children” in Kiniarwanda. The Nkundabana project consists of adult mentors who are trained to assist child-headed households. They give psychosocial support and guidance by providing the orphans with advice about hygiene, health and children’s rights. As a result both the material and the psychosocial needs of the orphans are met.

Shaping the future

On the last day of our journey, we accompanied the commissioner Louis Michel during his meeting with Rwanda’s President, Paul Kagame. The president stressed the importance of development cooperation. The government has ambitious plans for Rwanda. Inadequate health care, poor infrastructure, lack of access to education, high population growth and poverty are the main focus points of the policy. Health care should be improved by providing treatment access for the most needy people and retaining competent health professionals. President Kagame promotes awareness of the effects of genocide and the consequences for children, in particular orphans. We should not be discouraged by the multitude of problems war struck that countries face, but make childcare an immediate necessity. The legacy of the genocide must not turn into a legacy of lost dreams!

$/ Rwanda

9 464 000 inhabitants

730

income per year

♂ 51yrs ♀ 53yrs life expectancy

Simon Rock, medical student from Rwanda

What you wrote is true but it is like a drop of rain in a desert. The article is based in Kigali and there orphans are a bit taken care of by NGOs but orphans in the countryside hardly get care. We need to be more realistic on this issue. Personally, I am an orphan having other three to care for.

’’

Further Reading

  United Nations Development Programme and Government of Rwanda. Turning Vision 2020 into reality. National Human Development Report. 2007   Boris NW et al. Infants and young children in youth-headed households in Rwanda: implication of emerging data. Infant Ment Health J. 2006: 27(6), 584-602   Thurman et al. Psychosocial support and marginalization of youth-headed households in Rwanda. AIDS Care, 2006: 18 (3), 220-229

$

7.2%

of GDP for health

/

0.05

doctors/1000 people

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Quantity of Strive The daily wash is done amongst the floating bags and waste. Taken in 2005 on a lake in Bali, Indonesia. The island paradise, like the rest of Indonesia, has its share of poverty and inadequate hygiene. Health is dependent on a multitude of infrastructures.


The theme of the the annual IFMSA-NL congress in February 2008 was Safe Motherhood Both photos are contributions from the winner of the photography contest, Mike Sunner Bloem.

The theme for Global Medicine’s next photo gallery will be Nutrition and health. Would you like to have your photo published on this page? Send your contributions to editor@globalmedicine.nl More information available on our website www.globalmedicine.nl The Path Ahead Taken in 2004 in the Red Cross Children’s Hospital in South Africa. One of these mothers was recently diagnosed with HIV/AIDS. It has been estimated that a third of the adults in South Africa are HIV positive, resulting in numerous orphaned children. The path ahead is dim with fear.


Undocumented migrants Access to health care Mirte Sprengers The right to the highest attainable standard of health is a bundle of obligations on states and others and the challenge is to hold the dutybearers to account. Paul Hunt, UN-expert on the right to health. (April 2008) When you read these words of Paul Hunt, you might immediately think of poor people in Africa not being able to get health care. But don’t forget the vulnerable groups in your own societies! There are approximately 5 to 8 million undocumented migrants (UDMs) in Europe who often remain unseen by policymakers. Although every person has the right to health care regardless of their legal status, appropriate care is not always provided. The

problem often lies in their access to, not in the quality or availability of health care. This article reviews that problem.

a permit. In each case the reason for escape is important enough for the individual to risk remaining illegally in the host country.

Undocumented migrants

"The doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive, whether personal, collective or political shall prevail against this higher purpose."

UDMs are people, often refugees, who do not have (or did not apply for) a residency permit for the country to which they have fled. These people cannot return to their homelands for several reasons: it is simply too dangerous, they do not have passports or they are too ill to travel. Often the serious problems the refugees would encounter upon return to their own countries are not recognized by the host country. Heavily traumatized refugees might also fail to tell a consistent story, and this can lead to denial of

$/ The Netherlands

16 379 000 inhabitants

37 940

income per year

♂ 78yrs ♀ 82yrs life expectancy

Health problems UDMs often cope with multiple and serious health problems, acquired before or after migration, or both. Refugees often come from countries with poorer health facilities than in Western countries. Often there are no vaccination programmes in the individual’s home-

$

9.2%

of GDP for health

/

3.15

doctors/1000 people


Right to health care If UDMs get ill, they should be able to find health care, even if they do not have a place in the regular system. This is an issue of human rights that has been recorded in several important international documents. According to the UN commission on Economic, Social and Cultural Rights (UNESCR), states are under the obligation to respect the right to health by refraining from denying or limiting equal access for all persons, including [...] asylum seekers and illegal immigrants, to preventive, curative and palliative health services.

The right to health is also secured in the Universal Declaration of Human Rights (UN, 1948). This means it applies to every human being, including people without legal status. Several codes on medical ethics help health workers in taking decisions. The main thrust of such codes is to ensure that physicians consider the health of the patient as their first and most important consideration: A doctor must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive, whether personal, collective or political shall prevail against this higher purpose (Tokyo Declaration, World Medical Association).

Access to health care: the problem But law and ethics mean nothing if not properly implemented. Still, only one third of the UDMs in Europe with a chronic disorder receive treatment. Governments forget too easily the obligations imposed upon them by international human rights conventions. In Europe, different policies are in place. All of them however fail, some more so than others, to provide UDMs with the necessary accessibility to health care.

IFMSA-NL ARTICLE

land, and the prevalence of communicable diseases (e.g. TB, HIV) and psychological problems (Post Traumatic Stress Syndrome resulting from experiences during war, torture and loss of relatives) is higher. Secondly, the way refugees typically travel, hidden in trucks or packed by the hundreds into tiny boats, can lead to health problems. Once they arrive at their destination, they face new problems: finding shelter, coping with unemployment, keeping their illegal status from being discovered. This often leads to depression and other psychological problems.

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IFMSA-NL Medical students worldwide are united in the International Federation of Medical Students’ Associations, IFMSA. We organize student exchanges on wards and research labs all over the world, and run local, national and international projects in the field of Reproductive Health, Medical Education and Public Health. The working committee on human Rights and Peace advocates among other for awareness on refugees. IFMSA-NL has over 500 active members on the eight Dutch medical faculties and is also part of the European network for medical students, EMSA. www.ifmsa.nl – Think Globally, Act Locally

IFMSA-NL is part of the IFMSA and EMSA networks

Economic accessibility Generally speaking, undocumented people do not have a steady income and are not allowed to have medical insurance. Since medical procedures are very expensive, this poses a serious financial problem for UDMs in countries where health care is only provided on a cash-payment basis, as in Austria and Sweden. The tragedy is that regular medical care is often vastly cheaper than the emergency treatment that results when regular medical care has been unattainable, and ironically, emergency treatment is always covered by the government. Physical accessibility In some countries, as in the Netherlands, certain hospitals or health centres are appointed to take care of UDMs. Although this system might be characterized by improved quality of care offered to UDMs by experienced health professionals, it might also be characterized by problems of accessibility, as it requires patients to travel to a particular location, and travelling costs may be prohibitive for sick people. Health care as a tool for the immigration office Right wing politicians argue that providing free health care would attract even more immigrants and would encourage people

to stay in their countries illegally. Research, however, concludes that health care is not a pull factor for migrants, nor is the denial of medical care a push factor. But some countries take it even further. In Germany, all public institutions, including hospitals, are obliged to report any and all encounters with undocumented persons to the Foreigners Office. The Foreigners Office will then take action and start the deportation procedure. As a result, undocumented persons are afraid to seek health care. Lack of information Even if the policies are reasonable, they often fail to provide good access to health care because health workers and UDMs do not know about them. A receptionist might not know what to do when a person comes without an insurance card; a doctor might not be sure whether to report the patient to the Foreigners Office; the patient might not know his rights and entitlements. Because policies in neighbouring countries are so different, the situation becomes confusing for the UDMs.

The Netherlands In the Netherlands, health insurance is obligatory. Although this is not possible for UDMs, Dutch law ensures that they have access to necessary medical care too. Only a doc-


tor can decide whether medical procedures are necessary. Access to health care for UDMs in the Netherlands is generally good, although there is also a lack of knowledge about policy guidelines. For example, a small study showed that 68% of uninsured patients were refused care by non-medical personnel, like receptionists, in 2007. Recently, the Dutch government adopted a new law, which provides more funding for the health care of UDMs than was previously provided. The downside of this law is that only 80% of treatment costs will be subsidized, leaving 20% for the patient to cover. In expensive cases, these costs might be covered by the treating health care organ­ ization.

Conclusion Access to health care is a problem in many countries hosting UDMs. These people have the right to health care and doctors should treat them according to their ethical codes. Governmental policies differ between countries, but none leaves enough room for doctors to provide good care. These policies influence access to health care by creating financial, physical and informational barriers. We should hold the duty-bearers to account, as Paul Hunt said.

Get involved! Many NGOs are working on this issue. You can join them or set up your own project. Lobby to change policies, inform fellow students, doctors, other health workers and even UDMs by writing articles, making leaflets, organizing debates or garnering attention for these issues in the curriculum! You can join the network on projects on UDMs of IFMSA (International Federation of Medical Students’ Associations) and IPPNW (International Physicians for the Prevention of Nuclear War) by sending an empty email to undocumentedmigrants-subscribe@ yahoogroups.com. Don’t hesitate to ask for help or inspiration!

Further reading   United Nations International Covenant on Economic, Social and Cultural Rights. 1966   PICUM. Report; Access to health Care for Undocumented Migrants in Europe. 2007   Rapport Commissie Klazinga. Arts en Vreemdeling. Medische zorg aan (dreigend) uitgeprocedeerde asielzoekers en illegale vreemdelingen. 2008

One night, I had to go to the hospital. I had been in pain for a long time and thought I might be bleeding internally. I think I waited too long, because I was afraid of getting arrested by the police. I didn’t know exactly what to do. An ambulance would be too expensive for me. I eventually took a cab to the hospital around noon the next day. I had to make an arrangement with the hospital about the payment. Today I feel fine but I’m very worried about the costs. (Testimony of an undocumented woman, Médecins du Monde, case from The Netherlands) G is an Arab man whose nationality is disputed. He suffers from bowel cancer, and was admitted because of uncontrollable bleeding. The clinicians in A&E (accident and emergency departments) scheduled him for an operation as soon as the bleeding stopped. However, once the hospital discovered G was a refused asylum seeker, he was given a bill for many thousands of pounds and his operation was cancelled. He was discharged from hospital and told to come back ‘when his condition deteriorated’. (Case from United Kingdom) A severely ill undocumented Chinese man went to the hospital in Vienna and had a serious but successful stomach surgery. Eighteen days after he left, another undocumented Chinese man with grave stomach pain, came to the hospital using the identity card of the first one. Immediately, he was taken to surgery, the treating physicians relied on the medical history from the first patient. During surgery, the patient’s life was in real danger. Luckily, the doctors realized in time that the patient’s blood type did not match the blood type mentioned in the records. This saved his life.

IFMSA-NL ARTICLE

Stories from refugees

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Blue tulip Filip Dąbrowski A Polish medical student recounts his experiences with Dutch health care. When I arrived at Schiphol International Airport I didn’t have the slightest idea what to expect from the Netherlands. I was so confused that questions like Do they have duty free coffee shops? and Do they have cars, or only bikes? were chasing each other in my head. It was the first day of my summer holidays; the Sunday sun was shining merrily in the sky. I picked up my bag and went out to discover Amsterdam. Next morning, nine o’clock, I started my internship at the endocrinology department of the Vrije Universiteit Medisch Centrum (VUmc). I crossed the enormous bike-parking-lot to meet my student tutor and start one of the biggest adventures of my life. I always regarded Dutch medicine with respect, but what I saw that morning was much better than I ever imagined. I felt like a kid in a candy shop. After I got an electronic photo ID-card I tried on

A thirty year old male-to-female came for a control visit during ‘hers’ hormone therapy. the white coats emblazoned with the VUmc logo, which are tailored differently for doctors, nurses and other staff members. This system allows everyone to recognize each other’s position immediately, and no one has to wear coats from pharmaceutical companies.


COLUMN

But I could not take my new coat with me! A few moments later my tutor explained to me how to use the ATM-like machines in the corridors. Every morning you just hold your ID card up to the scanner, and pick up a freshly laundered coat! I started my internship in the endocrinology laboratory, discovering technical and scientific innovations. What I enjoyed most was the big role students have in scientific work. Every Dutch medical student, after his fourth year at university, joins a research team for three months. After completing this research project, clinical rotations begin. After more than four years of theoretical classes he can finally touch a patient! I finally understood why my Dutch friends were so jealous of me – I saw my first patient two years earlier!

My only regret is that I didn’t buy the bulb of the blue tulip. After the laboratory work I started at the outpatient clinic. When I saw the waiting room full of patients, suddenly I felt at home. Someone was reading an old magazine; someone else was taking coffee from the machine… But wait! Coffee was free! These little things set Dutch medicine so far ahead of other countries. What’s more, I was simply dazed by the variety of cases in everyday’s practice! An eighty-fouryear-old acromegalic came twenty kilometres on his bike to the doctor’s office. When I thought that nothing could surprise me anymore, I was invited to attend the ‘gender clinic’. Although I don’t consider myself a very conservative person, consulting my first patient there was probably the largest culture shock of my life. A thirty year old male-to-female came for a control visit during ‘hers’ hormone therapy. If that was all, I could have kept my professional face without any troubles, but it turned out that (s)he had brought her seven-year-old son along.

I spent one week assisting doctors in the internal medicine ward in the hospital. This time I thought that it would be similar to the departments in Polish hospitals. Again, I couldn’t be more wrong! Clinical rounds do not start at eight, but around ten in the morning, and before visiting the patients, the doctor listens to a report of a nurse who took care of the patient during the night. I like this system very much, and it works well for training new doctors, too. Although these first impressions might sound hilarious, at the beginning I was completely confused. Luckily, this state changed quickly when my tutor showed me the city, gave thousands of tips and introduced me to other exchange students. Together we discovered eve­ ry nook and photographed every stone in Amsterdam! Yet, even if the Leidseplein life means nothing to you, you simply have to try to leave work early to survive… Almost every shop (except maybe ‘smart’ ones), most of the museums and all offices close at five p.m., which was typically the time that I would leave the hospital. Sometimes I got the impression that doctors have to take a day off to buy shoes or buy groceries! My only regret is that I didn’t buy the bulb of the blue tulip – I guess it means that someday I have to come back to the Netherlands!

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Gender inequality in Southern Sudan In June 2007, Thekla Bosschaart went to Mundri, a small village in Southern Sudan. Together with eight other Dutch students and a supervisor she started the health education project Mpower! Your body, your responsibility. They trained 62 young Sudanese people to give workshops about Hygiene & Sanitation, Nutrition or Sexual & Reproductive Health (SRH). Thekla focused on the latter.

Thekla Bosschaart Catherine is a woman somewhere in her thirties (in Mundri no one knows his or her exact age). Catherine is strong, empowered, independent and educated, she runs her own business. She undoubtedly has the potential to be a role model for other women in her community. Catherine was married to James, but unfortunately they remained without children even after several years of marriage. Due to this reason, James was advised by his family to marry another wife: This one is no

good. Catherine was blamed for their failure to conceive and was insulted and harassed by her in-laws to such an extent that she finally packed her bags and returned to her own family. James will find no problems in marrying another, Catherine will. Establishing a family in Mundri is very important, as in many other (East) African countries. Catherine felt very pressured by her family, her husband’s family and the rest

$/ Southern Sudan

10-20 million inhabitants

< 750

income per year

~ 35 yrs

life expectancy

of the community to have children. Catherine: A big family is your security for the future and it gives great respect (especially to the father of the child). Beliefs about the causes of infertility in Mundri are very different from Western beliefs. Infertility is always seen as the womanâ&#x20AC;&#x2122;s fault. People believe that dowry, witchcraft, eating the wrong kind of food and parental discontent with the chosen partner of their daughter can make a woman infertile.

$

no data on %

of GDP for health

/

unknown number of doctors/1000 people


ARTICLE

Catherine: Dowry is paid to the woman’s family when she marries. Most of the dowry will be given to her uncles. If they think it is not enough, her uncles will become angry and annoyed. They start speaking evil of their niece, which in turn causes her to become infertile. To change her fortunes, extra payment is needed. The effect of too little dowry can even skip a generation. When the dowry paid for my mother was not enough, this can cause me to become infertile. Also my parents can influence my fertility. If I would marry a man against the will of my parents, they will make sure I will not receive. So how come teenage girls who have sex against the will of their parents become pregnant? That is because their parents did not know about them having sex. Another cause of infertility in Mundri is eating men’s food or visiting places not suitable for women. For example, the blacksmiths’ is perceived as a place where only men can come. It is believed that women can become infertile when visiting this place. Culture can help explaining things that happen in one’s life, things that we do not understand, that we cannot see with the naked eye, like infertility. The main problem here is not so much that people in Mundri are con-

“When the dowry paid for my mother was not enough, this can cause me to become infertile.”

27

vinced that dowry, witchcraft or eating the wrong food can cause infertility (who are we to say that this is not true?). It is the inequality between men and women in these beliefs that is worrisome. Men are not even considered to have a role in the failure to conceive. At the same time, women like Catherine are cast out by the community; they are looked down upon and stigmatized. Their strengths are completely ignored.

Achieving more equality between men and women would not only be beneficial for women. The pressure on men to produce children and divorce when faced with reproduction problems might decrease as well. Gender equality can also have positive effects on a community. It can incite economic progress and growth, and reduce child mortality. Gender inequality affects the access to and use of health services, treatments and


Mpower! Your body, your responsibility

Mohamed Abdelsadg medical student in Khartoum, Northern Sudan

I found the article really interesting. I think it could be true, especially if we are talking about a village that is not well known even among Sudanese. To be honest I have not heard about this village before, though I am not saying it’s not there!

Mpower! Your body, your responsibility is a joint project of IFMSA-NL and the Mundri Relief & Development Association (MRDA) from Southern Sudan. Nine Dutch students worked together with Sudanese youth in a Training of Trainers programme that took place in 2007. Over a six month period, 62 Sudanese young leaders were trained in Nutrition, Sexual & Reproductive Health and Hygiene & Sanitation. Through interactive workshops and small group projects, self confidence and teamwork among the participants was promoted. The Sexual & Reproductive Health sessions focused on, among other, gender

differences & similarities, infertility, pregnancy & labour, sexual transmitted diseases and safe sex. The Mpower! project aims to increase knowledge about the abovementioned themes and to boost independency and enterprise among the participants. Mpower! was succeeded by Mpower!kids, a Training of Trainers programme focussing on child health, nutrition, hygiene, children’s rights and education. Mundri, Southern Sudan, now owns a Youth Friendly Centre and a Mother & Child centre. For more information on the Mpower! project visit www.ifmsa.nl/mpower

decreases the incidence of sexual violence. Development cannot be seen separately from cultural beliefs on gender matters.

Eventually though, I got the feeling that most of our participants took the roles of both women and men into consideration when discussing infertility. Hopefully, this is a first step towards better gender equality in Mundri.

Catherine was a volunteer in the Mpower! project. During the SRH workshops, we attempted to change the unfortunate situation of women like her. First we tried to add – what Western science sees as – the real causes of infertility to their traditional beliefs. Through role-plays and discussions, we tried to take the blame off women. Culture and traditional beliefs however, can be a hard thing to change.

Further reading:    Gender equity and socioeconomic inequality: a framework for the patterning of women’s health; Nancy E. Moss; Center for AIDS Prevention Studies, University of California San Francisco    Gender, Sexuality and HIV/AIDS: the What, the Why and the How; G.R. Gupta; XIIIth International AIDS Conference, Durban, Southern Africa; July 2000


STUDENT BMJ ARTICLE

Hinduism: Life and death Article adapted from Student BMJ Shaheen E Lakhan This article considers Hindu bioethics as they relate to biotechnology, suicide, euthanasia, and organ transplantation and donation. To understand bioethical dilemmas from a Hindu standpoint, you must be familiar with the law of karma and beliefs about reincarnation.1-3 The theme of Hindu bioethics is that death is not opposite to life; rather, it is opposite to birth. Hindus consider life to be a journey between birth and death. In Western society, health is understood as freedom from disability.4 In Hinduism it is understood as soundness of body and mind. Deviation from this balance results in illness; one commonly held belief among Hindus is that illness is instigated by bad karma. However, many Hindus consider illness simply as part of ordinary life experience and also as a test from God.

Law of karma In Hinduism your perpetual soulâ&#x20AC;&#x2122;s future and the quality of your rebirth and progress towards liberation depend on your actions in life. The law of karma states that every event has a cause and effect, and every cause has a destiny. It signifies the interplay between fate

and free will. Hindus are not fatalists who believe that humans have no freedom, are subject to preordained forces, and are puppets of fate. Karma is accumulated through prior existences and defines your character, tendencies, capacities, and caste. Hindus seek a high

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quality of birth as measured by your longing for God and not for worldly things. The system of karma perpetuates transmigration that results from ethical or unethical consequences. Hinduism also differentiates acts of death, according to the Vedas and Laws of Manu. Therefore, possessing some familiarity with Hindu ethics permits you to consider bioethical dilemmas through the lens of Hindu religious order.

Doctrine Hinduism is one of the world’s oldest relig­ ions and cultural systems, predating recor­ded human history, and has no one particular human founder. The underpinning scriptures, the Vedas, act as the universal Hindu

framework, and the Bhagvad Gita and the Upanishads are the scriptures’ refinement and integration. The atman is the supreme universal self and the deepest essence of each being, and the Brahman pervades the individual. The physical portion of the human being is the human body, a vulnerable vehicle within the ceaseless atman. Akin to most other religions, there are generational differences in emphasis and interpretations, which extend to practice. The Vedas are the Indo-European Sanskrit texts, containing hymns, incantations, and rituals. The Upanishads incited intense philo­sophical speculation of such practices, but clarified the merger of atman and Brahman through contemplation and mediation. As the largest book in the world and the national epic of India, the Mahabharata pre­sents intriguing visions of humanity and the divine.

Reincarnation Hindus believe that all beings can move towards enlightenment through life actions and progression, through cycles of rebirth – a system of reincarnation. The atman holds the potential for infinite succession and permutation, transcending many lives and undergoing innumerable experiences before merging with the divine. Death initiates the disconnection between the physical body and

the mind; with reincarnation, the body and mind keep returning to Earth until reaching supreme liberation. Hindu doctrine accepts suffering as inevitable even in death. Hindus are urged to seek a good death through a conscious dying process and to select discomfort over drugs. The last moment of your life is especially important to determine the properties of your rebirth. Your extended family should be near and either you should chant a mantra or a family member should intone Aum Namasivaya, a powerful hymn that leads you along the path to enlightenment.

Biotechnology Despite a lack of scholarly literature on Hindu bioethics, recent interest has prompted its articulation within the scope of issues of life and death. We cannot view bioethics merely

Hinduism generally perceives suicide as an act against humanity and a mortal, reprehensible act of destroying lives as medical ethics conjoined with moral principles because bioethics are not the bastion of only medical professionals. Advances in biotechnology and medical treatments have yielded complex public affairs, so when a traditional code of beneficence fails to con-


STUDENT BMJ ARTICLE

jure adequate solutions, examining bioethics from other cultural perspectives such as Hinduism can be useful. For example, India, a predominately Hindu nation, created a National Bioethics Committee in direct res­ponse to biotechnological innovations, including stem cell research.5,6 On the other hand, India has been slow to consider issues of transgenic or genetically modified crops.

Suicide and euthanasia Hinduism generally perceives suicide as an act against humanity and a mortal, reprehensible act of destroying lives. Suicide would be considered a bad death because according to Hindu doctrine, bad deaths are violent, premature, and uncontrolled and occur in the wrong place and the wrong time.7 However, it makes two important distinctions between suicide and euthanasia. If you commit suicide for what Hindu doctrine considers selfish reasons, such as financial burden, it reflects the individualâ&#x20AC;&#x2122;s ignorance about the nature of life and human destiny. A person who commits suicide will still continue the samsara, the cycle of birth, suffering, and death. People who aid such suicides are burdened with karmic punishment because they have violated the principle of non-violence. If an individual seeks death consciously and willingly for the spiritual intention of compassion or liberation, however, a different

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World religions: Hinduism

Christians 33%

Other religions 22%

Muslims 20%

Non-religious 12%

Hindus 13%

13% of the world’s population consists of Hindus, which is 970 million Hindus worldwide.

60 million followers live outside of India

Most important Gods of Hinduism: Brahma, Vishnu, Shiva, Krishna, Rama, Durga, Ganesha

Traditional medicine system of Hinduism: Ayurveda (‘Science of long living’)

perspective surfaces. Concern for the wellbeing of others by hastening your own death consciously can be a sign of spiritual enlightenment and so would be considered a good death. Modern figures have sought deliberate spiritual enlightenment by way of self willed death by fasting (prayopavesha). The Laws of Manu allow prayopavesha for ascetics, members of the Brahmin caste, and kings. If you permit your body a slow and wilful dissolution you are free from sorrow and fear and are ultimately liberated. However, you must publicly announce this intention and permit community intervention, if any is offered. If, in the face of physical suffering that hinders discipline the individual seeks spiritual liberation, Hindu doctrine permits the shortening of life. Yet, lack of consciousness due to pain, mental illness, or lethargy impedes full perception, which is necessary to ensure favourable rebirth. Extreme suffering results in attachment to the material world and hinders the pursuit of spiritual liberation. In cases of a lack of consciousness and extreme suffering, euthanasia by a doctor’s injection with lethal drugs is sometimes a compassionate act. However, any measure of assisted suicide preventing patients from comprehending their descent towards death or rendering them unconscious presents a moral quandary.

Organ donation and transplantation Cremation is a big part of samskara funeral ceremonies, and is both a destructive process and a course of creation. As the physical body and mind reunite with the Earth during the final act of cremation, the atman continues the samsara cycle after 12 days of wandering. If the body reunifies with the Earth without the original set of organs, will the atman be allowed to continue samsara, have karmic repercussions, and be reborn? Organ donation in Hinduism is considered charitable and possessing of karmic benefit,

No specific religious law forbids organ transplantation and donation yet many people also believe that if the body is incomplete during samskara the atman of the dead is suspended in a “state of animation,” and family members assume a karmic burden as a result. None the less, no specific religious law forbids organ transplantation and donation. The benevolent act of organ donation, when permission is explicit, transfers tremendous karmic merit and virtue to the donor and would take precedence over organ withdrawn body cremation.


Healthcare providers should be familiar with the convictions of this patient population to determine optimal management. Also, we must accept that our patientâ&#x20AC;&#x2122;s religious and spiritual bases must not automatically be deferred to clergy. If we show a basic understanding of our patient when deciding to undergo organ transplantation, for example, we can offer more than medical statistics and establish a more therapeutic doctorpatient relationship.

Clinical scenario An 85 year old Indian born man presents with idiopathic fulminant hepatitis, with massive liver necrosis. He informs you he does not want to live his final days on a machine and does not fear death because he sees it as a process of life. His prognosis is bleak; without a liver transplantation he will likely die. He is at immediate risk of hepatic encephalopathy and cerebral oedema. Preoperative management would dictate airway protection by a nasogastric tube to prevent aspiration and intubation if a coma is imminent. Although liver transplantation is the definitive treatment, it may conflict with the patientâ&#x20AC;&#x2122;s beliefs. Even if he accepts transplantation, he is in a group at high risk of mortality and may not survive the procedure. This

Hindu patient thinks that under anaesthesia he would not benefit from a proper dying process. Also, he does not want to live on intensive care support measures in his final days, either from direct medical management of the fulminant hepatitis or as a surgical complication of the transplantation. Doing so would conflict with Hindu doctrine and he will be left weak and severely ill. In this case, most traditional Hindu families would not prolong life through medical measures out of consideration for the patientâ&#x20AC;&#x2122;s old age as well as the perception that it may unnecessarily prolong an inevitable dying process. Therefore, we must apply palliative care to ease pain and permit a conscious comfortable death.

Original publication & references This article is republished from Lakhan, S.E. Hinduism: life and death. Student BMJ2008;16:310-311. All references are available online at http://student. bmj.com/issues/08/09/life/310.php

STUDENT BMJ ARTICLE

Implications for the healthcare provider

Conclusion In relation to modern medical and scientific issues, Hindu scripture is not prescriptive. Instead it provides insight into how to approach ethical dilemmas. Morality often leaves the decision to the individual, and intention, as in the case of suicide, is a key aspect. None the less, the significance of deeds in the current existence is diminished because the karmic profile is collected throughout the eternal atman journey of numerous cycles of birth, affliction, and death.

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Studying medicine in…

Lisbon Nuno Costa Monteiro (25) is a sixth year medical student from Lisbon, Portugal.

How is university life in Lisbon? We have many academic, traditional festivities. The most notable is the Queima das Fitas – a graduation celebration, symbolized by the burning of ribbons with the colours of each faculty. Though such rituals are seen as outdated by some people, it remains an important reference in the academic experience of any student. One of the most visible and distinctive traditions is the use of the academic costume, which is a black suit and cape used on special occasions. Do you live with your parents or on your own? I still live with my parents – no expenses, good home meals, clean clothes: big comfort! But if students come from another city, they usually share small apartments with colleagues. How many hours a week do you study? In the final year, we divide our time between hospital work and studying at home. We really need to be well organized, because the final exam in October determines our speciality. I try to study three hours on week days and six in the weekend. Is it financially possible for everyone to study medicine in Portugal? The biggest difficulty is to get in medical school. Competition is high and the places are few. We don’t receive any financial support from our government,

except if we apply for scholarships. It’s quite a complicated process, but there are some grants for those in need. What is good about Portuguese medical education? We start dealing with patients at an early stage. Furthermore, we have the possibility to do clinical work in almost all hospitals of Lisbon. This allows us to learn different approaches in similar situations. Now, in the last year, I have (almost) full responsibility for patients, learning and working at the same time – for me, it’s the best! You experienced Dutch university life through an exchange programme two years ago. What do you think is the biggest difference between studying in Amsterdam and Lisbon? Educationally, I think we are not far away from each other. In Portugal, we don’t have the models to practice techniques, like intubation or injections, before doing it on real patients. I really thought that is a great way to learn. Describe your life in 2020… I’ll answer that in 2010 – the year I will know my speciality. Until then, I can just describe what I will do tomorrow…


GMMIX

Colophon Global Medicine is an official IFMSA-NL publication. Editor in Chief Emmaline Brouwer Project coordinator Richard Schol Editors Naomi Begemann, Machteld Julsing, Evi van der Linden, Marjolijn Paauwe, Julia Spierings, Daniëlle Stuijvenberg, Rik Viergever Art directors Patricia Hordijk, Roel Klein Wolterink, Lies Schakelaar Finance & Logistics Frederiek Bosscher Public Relations Minke van Minde, Rahana Parbhudayal, Andrea Tancica Webmaster Richard Schol IFMSA-NL Liaison Minke van Minde Proof-readers Titia Begemann, Doeko Bosscher, Sherrill Rose, Faiza Safiruddin Printing Hollandia Printing, Heerhugowaard (NL) Contact editor@globalmedicine.nl Internet www.globalmedicine.nl

Book reviews Africa is contagious by Steven van de Vijver There is only one First Time for everything. Those first times are memorable, because you have no memories yet and your head is entirely empty. This is a book filled with first times of Steven van de Vijver, a doctor from Holland, going to Baraka, Africa to help the people as much as possible. Working for Médecins sans Frontières, he discovers the mentality, environment, government and especially the diseases and hospital in which he works. There is no continuing story from beginning to end; the book is merely a summarization of all the memorable things he encounters on his journey. Definitely something to read if you are looking for a true story about life as a doctor in a developing country.

ISSN 1474-4345 Global Medicine is being distributed free of charge among the eight medical faculties in the Netherlands and selected faculties world wide. The printed edition has a circulation of 8000 copies and is produced three times a year. The magazine is also available through our website www.globalmedicine.nl. Except where otherwise noted, this work is licensed under the Attribution-Non-Commercial-Share Alike 3.0 Netherlands Creative Commons licence. In summary: You are free to copy, distribute, display, and perform the work and to make derivative works, under the following conditions: Attribution / Non-Commercial / Share Alike. View the full licence at www.globalmedicine.nl/ licence before (re)using any content. p29-33 © BMJ Publishing Group Ltd 2008, all rights reserved. Statistics p6/10/11/17/20/26 adapted from WHO, p32 adapted from Encyclopedia Brittanica 2005. Photos & illustrations p7/8/15/24 © by Amfion Fotoshoots (Antonette de Groot-Klootwijk), photos for Global Medicine, all rights reserved. p18/19 © by Mike S. Bloem, all rights reserved. p27 © by Heleen van Dam, all rights reserved. Available under Creative Commons licences: p1 Giles Booth, THomas Hebert; p4/5 WHO, Lars Kristian Flem, Andy Langager, zyrcster; p21 Ivana Jurcic; p22 Sarah McD; p28 Roel Klein Wolterink; p29 Dey Alexander; p30 Marco Fedele; p33 Gabisa Motonia; p34 Pear Biter. Photos released under a CC-Share Alike licence can be found on our website.

Desert Flower by Waris Dirie The autobiography of Waris is a history of a small nomade child from Somalia who runs away from her family and homeland. She tells about her brutal experience with female genital mutilation. She runs away when her parents decide she should marry an old man. Waris only knows life in the desert and never saw anything like civilization. Her journey starts in the capital Mogadishu and via London she ends up in New York. There she is discovered as a high fashion model and later becomes a public person who fights female genital mutilation as ambassador of Amnesty International.

The prisoner by Malika Oufkir Malika is the daughter of general Oufkir who is minister of defence. As a child she grows up as a princess in the palaces of King Hassan II. She lives an excessive, luxurious and privileged life. When her father consults a coup, the king has no mercy for Malika, her mother and her brothers and sisters. General Oufkir is executed immediately and Malika and her family are imprisoned and isolated. Malika tells how they lived like prisoners in ghastly circumstances for twenty years. They live with rats, spiders, without personal hygiene and are subject to the harassments of the guards. Extremely malnourished they face terrible diseases.

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