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February 2009 - Issue 3 MEDSIN-UK PRIORITY CAMPAIGN 2008/2009: HEALTHY PLANET

healthyplanet@medsin.org www.uclmedsin.org/healthyplanet.htm

Medsin UCL’s Global Health Magazine

A healthy environment is vital for a healthy life. From air pollution in inner-city London and respiratory disease, to droughts and widespread famine in sub-Saharan Africa, our environment is constantly affecting our health. HEALTHY PLANET is the student campaign on climate change and health. The health profession is one of the most important groups to mobilise against climate change and as future health professionals, we can have a major impact.

Letter from the Editor

At UCL we need YOU to help us in: ORGANISING the March 7th Healthy People, Healthy Planet South-East Regional Conference on Climate Change & Health. See www.uclmedsin.org for details and to reserve your place. LOBBYING the medical school and the UCL Institute for Global Health to use it’s position between students and health professionals to promote climate change orientated education and practise. WORKING alongside organisations such as Medact, the Campaign for Greener Healthcare, and the Climate and Health Council to advocate for greener policy change within the NHS

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INTERESTED? Email healthyplanet@medsin.org and get active today!

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February 2009 - Issue 3

Medsin UCL’s Global Health Magazine

Meet the Team

Contents »

Current Affairs

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Letters

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Neglected Tropical Diseases

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Preaching Prevention: The Importance of Understanding Local Knowledge

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Interview

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The failure to eradicate polio How will the financial crisis affect Global Health?

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Core Editors Vishaal Virani, Katie Birley, Joyce Browne, Katherine Law, Rachel Scott, Katharine Langford Copy-Editors Aadarsh Shah, Emily Savell, Kate McAllister, Nikhil Patel, Jonathan Cheah, Saameendra Das Design Team Saameendra Das and Ruth Batham Cover Photo Joyce Browne Writers Laura Cordier, Michael Malley, Ragulan Ravirajan, Maria Bartkiewicz, Natasha Lyons, Rachel Scott, Leena Patel, Alisha Allana, Emily Savell, Lucy Reeve, Elena Ferran, Katherine Pitt, Aadarsh Shah, Anastasia Hadjivassiliou, Camus Nimmo

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Women in Sub-Saharan Africa—Can they say no to HIV?

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Vaccines, Dubious drugs and Malaria

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Tuberculosis: The fight for essential medicines

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What’s going on...

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Webmaster Joel Cunningham

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Reviews

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Please visit our website to view this magazine in PDF format: http://www.uclmedsin.org

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Fun facts and light relief

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For full article references see the online version

Letter from the Editor

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elcome to the third and final issue of Perspectives for this academic year. I would like to take this opportunity to thank all the editors, writers, designers, and most importantly the readers, for contributing to the magazine this year. I hope you will all remain involved with the magazine in the future.

Medsin UCL has been very active this year, and this magazine is only one of many projects the society has been involved with. We are currently co-coordinating the Universities Allied for Essential Medicines campaign, which aims to make the research and development of medicines at UCL more accessible to developing countries. The Global Health Education Project aims to increase availability and access to formal global health education at UCL. To that end we are currently compiling a survey to assess demand for global health education amongst students. This year we have also seen the very first global health lecture, on Infectious Diseases in the Developing World, given to our 1st year Medical Students. Another Medsin UCL initiative, the Student Stop AIDS campaign, is currently pushing for Patent Pools, which enable production of cheaper, generic versions of AIDS drugs. Finally, on March 7th, Medsin UCL and Medsin’s Healthy Planet campaign will be hosting a one-day conference on “The Global Health Impacts of Climate Change” which will heavily revolve around students and student action. We hope that many of you will be able to attend. As always, these endeavours require the support of students so please do get involved. For more information about the Medsin UCL projects and campaigns please visit www.uclmedsin.org Vishaal Virani

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Medsin UCL’s Global Health Magazine

Current Affairs

February 2009 - Issue 3

By Camus Nimmo, Ragulan Ravirajan and Michael Malley

Indian Population Calls for Condoms Population statistics have been making worrying reading for leaders of the world’s largest democracy. India has a population of over 1.1 billion, 200 million short of neighbour China, who is predicted to overtake to become the world’s most populous country by 2030. This is going to leave a country that already squeezes 17% of the global population into 2% of the global landmass, with ever increasing competition for space and resources1. Almost 50% of women throughout India are married by the age of 18, and many become mothers soon afterwards2. Given that in many parts of the country issues such as family planning and contraception are taboo, the official target of reducing the current total fertility rate from 2.76 to the stable figure of 2.1 by 2010 seems next to impossible3. This has led the government to set up the ambitiously named National Population Stabilisation Fund. They have been running a nationwide call centre for the last nine months aiming to provide a reliable source of information to young couples, particularly in rural areas, who are too embarrassed to ask their parents or teachers about sex, condoms, abortion, and pregnancy. Initial reports have shown some success; with the seventeen staff taking over 25000 calls in the first six months from both women and men. However, recently call numbers have fallen – a problem blamed by call centre staff on the number not being toll free, which is likely to be a significant barrier to those most in need of access4. Meanwhile, figures from slightly closer to home have shown that since 2003 there has been a 50% increase in the number of Asian women living in the UK having abortions5. Experts have put this down to Asian women having ever more open relationships and pre-marital sex, which go against the traditional norms of Indian society. This trend is likely to continue and family planning services will need to adapt accordingly, in India and the UK.

Humanitarian Crisis in Gaza and Sri Lanka Tension has been rising in both Israel and Sri Lanka in recent months as governments, with total disregard for innocent civilians, are engaged in military offensives against rebel groups. In Gaza, over 1300 Palestinians have been killed by the Israeli armed forces. Furthermore, emergency medical supplies have been heavily disrupted due to blockades imposed on the region by the Israeli government. Collateral damage caused by excessive bombardment from helicopter airships and fighter jets have left many homeless, and without clean drinking water or sanitation facilities. The story is very similar, yet heavily under publicised, in Sri Lanka. The Sri Lankan army has been deliberately targeting schools, hospitals, and even orphanages in the northeast of the country, in attempt to break down resistance of the Liberation Tigers of Tamil Eelam, commonly known as the Tamil Tigers. The Sri Lankan government has also refused entry to aid agencies, hence denying the 300,000 displaced Tamil civilians any medical assistance. The Sri Lankan army has killed hundreds of innocent Tamil civilians, and many incidents of rape have been reported. Many observers have described the killing of countless numbers of innocent Tamil civilians, including A Tamil Tiger at a training camp pregnant women and children, as genocide. Unfortunately, with reporters banned from (Source: Sangam.org) the conflict zone in Sri Lanka by the government, this humanitarian crisis remains largely hidden from the public domain. The BBC and other media organisations also failed to acknowledge the protest for peace in Sri Lanka, involving 70,000 protesters in London on 31st January. This lack of media attention, compared to the coverage on the conflict in Gaza, is unacceptable and must be addressed.

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February 2009 - Issue 3

Medsin UCL’s Global Health Magazine

Measles – Europe’s Deadly Export? If you were asked to give an example of a previously eradicated disease being imported into a (relatively) thriving healthcare system, tuberculosis and the UK might spring to mind. You would of course be right. However, you’d be just as correct if you cited the re-introduction of measles into Latin America. The reason? A far-reaching result of Europe’s lax vaccination schedules. In 2000, 750,000 people died as a result of the largely preventable measles infection. In 2005, the World Health Organisation (WHO) resolved to reduce measles mortality by 90% before the end of the decade. A widespread vaccination programme ensued, with UNICEF targeting 47 countries for 90% vaccination coverage. The results are encouraging – worldwide mortality plummeted to 197,000 in 2007. Particularly impressive is the 93% mortality reduction reported in the Americas. Children being vaccinated in Brazil (Source: Corbis.com)

However, there is a different story among Europe’s most developed countries, which shared over 12,000 cases of measles (with 7 fatalities) between 2006 and 2007. The vast majority of these cases occurred in Britain, Germany, Switzerland, Italy and Romania, according to a recent report in the Lancet1. These countries share some of the lowest rates of measles vaccination in Europe. Uptake of the MMR vaccine in the UK is currently hovering around 85% (the WHO recommends 95% coverage, with two vaccinations per child to eradicate the disease) – this is a ‘hangover’ from the unsubstantiated connection of autism with the MMR jab. Yet the consequences may be felt more profoundly in less developed healthcare systems. Substantial outbreaks have been reported in otherwise measles-free parts of South America, which have subsequently been traced back to Europe. Writing in the Lancet, two doctors from the WHO European centre for measles labelled this spread “embarrassing”2. This spread also highlights the adverse impact of globalisation and foreign travel on global health. There is a real chance of eradicating measles across the globe. However, this will take a concerted effort and a widespread 95% uptake of the measles vaccine – a target that the world’s richest countries have a global duty to achieve.

A Shot in the Arm for Alcoholics? You wouldn’t think it would be a problem giving shots to alcoholics. However, a different type of ‘shot’ may well help recovering alcoholics – a monthly injection to prevent craving for alcohol. Naltrexone is a drug which blocks receptors in the brain responsible for the ‘highs’ drinking can produce. It has been available in daily tablet form for some time, but in 2006 the US Food and Drug administration approved a long-lasting formulation, which can be injected into muscle once a month. A small study has been undertaken in Cambridge, Massachusetts, which shows the injections decrease the frequency and severity of drinking sessions6.

Could injections cure binge drinking? (Source: Deviant Art)

Heavy drinking represents an enormous public health burden across the globe. David Rosenbloom, a specialist in substance abuse from Boston University, says these injections may have a “huge” significance for public health, and he envisages them being offered to repeat drink-drive offenders7.

At a time when the public health implications of binge drinking are constantly in the news, Naltrexone injections may yet prove a real ‘shot in the arm’ in the fight against alcoholism.

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Could your old car be made into an Incubator? It could be a Mini, affordable way of supplying some of the world’s most vulnerable children with vital life-saving care, and it’s certainly no Toyota! It’s a contraption built in Boston, USA – an incubator made entirely out of car parts, with heating provided by the headlights, a door alarm signalling emergencies and temperature controlled by the air filter! Gimmicky? Perhaps. However, the manufacturers of this ingenious piece of apparatus envisage a widespread use in many areas deprived of hospital machinery. Made from simple parts of any car, these incubators are rugged and easily repairable by local technicians, whilst spare car parts are virtually ubiquitous. A further bonus seems to be the price – whilst normal incubators can cost around US $40,000, this one costs just US $1,000. A 2007 study from Duke University estimated that 96% of foreign-donated medical equipment fails within five years of donation, and very often cannot be repaired. Thus many areas do not need more apparatus; they need reliability and easy access to spare parts. Dr Rosen of Boston University says that in his research of impoverished settings, no matter how remote the locale, there always seemed to be a Toyota 4Runner on hand (seemingly making the Toyota as abundant as poverty itself), which formed the basis for the prototype! 14% of neonates are low-birth-weight babies (those most in need of incubator support), and these births account for 60-80% of infant deaths3. The incubator How the incubator could look does have limitations though, as its effectiveness in reducing infant mortality (Source: ecogreenius.com) is dwarfed by simple, sustainable interventions. These include outreach visits during pregnancy, skilled care at delivery, and emergency treatment afterwards. It has been estimated that these factors alone could eliminate 72% of neonatal deaths worldwide4. The incubator may only be a drop in the ocean for the fight against infant mortality, but the idea of “organic resourcing” may not be – building equipment from locally abundant, simple and cheap materials. Next time you’re on a long journey, take a look around you and see what you could turn your car into!

Three Teaspoons of Food to Prevent a Hunger Crisis After the Christmas excesses, three teaspoons of food may seem miniscule. However, that is the dose of “Plumpy’doz” which, when given three times a day to children aged 6 - 36 months, is hoped will prevent a crisis of malnutrition in Somalia. A UNICEF programme is now underway in the region which aims to reach 100,000 children by mid-January. “Plumpy’doz” is a “Ready-to-use Therapeutic Food” or RUTF, and represents a crucial step in the delivery of nutrition on a large scale. It comprises a mixture of milk powder, sugar, peanut paste, oil, minerals and vitamins, and is one of the first such combinations to be used in advance of a crisis rather than for emergency relief during a crisis. The UNICEF programme comes after the price of imported cereals in Somalia rose 400% between 2007 and 2008 - attributed to worsening drought, a falling currency and a global food crisis. Somalia is second only to Zimbabwe in the list of countries worst hit by food inflation5.

A child in Niger with Plumpy’doz (Source: Msf.dk)

However, “Plumpy’doz” itself is scientifically unproven and some critics say the formulation is too expensive, despite only costing US $0.17 per child per day. An unofficial trial was carried out by Medicine Sans Frontieres in Niger in 2007, which yielded promising results. The RUTF technique itself was approved by the UN Standing Committee on Nutrition in 2007.

The results of UNICEF’s programme in Somalia may make a profound difference to the health of thousands of children, yet we will wait to see if it heralds a seismic shift in the prevention of malnutrition crises before they become humanitarian disasters.

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February 2009 - Issue 3

Medsin UCL’s Global Health Magazine

global news o global views

Letters

The War on Tobacco

In response to the article “The War on Tobacco: India & China”, in Issue 2 of ‘Perspectives’, I think it is important to look at who should be taking more responsibility for tobacco control. Developing countries are providing a niche for tobacco production, and tobacco companies are never far behind to fully promote the “benefits” that can be acquired from tobacco cultivation. The main temptation for tobacco farmers is the possibility of making more money, with the return being up to five times more than for maize. Schemes exist whereby loans are offered to help tobacco farmers begin cultivation, but then low prices are offered in return for the produce. This deficit to tobacco companies quickly grows and can eventually lead to dependence of farmers and large areas of a country on these companies. Farmers continue to pay off their debt with the production of more tobacco, creating an unregulated cycle of tobacco production. The government in countries like India and China appear to have little control over this growing problem. Smoking is portrayed as glamorous and encourages people to follow the ‘western lifestyle’. The UK has implemented schemes to help smokers quit, and has invested vast funds into advertising and educational awareness to this end. However, developing countries do not seem to hold the same interest. Is this due to a lack of resources or the simple problem of ignorance? The sad truth is that action often occurs only when the situation is dire and rapidly spiralling out of control. Global treaties such as the Framework Convention for Tobacco Control aim to produce more specific national tobacco legislation and control programmes1. This would allow tobacco production to be monitored and occur only within specific guidelines. The governments would then have better regulation of economic and social implications of the tobacco industry. With the publication of articles like “The War on Tobacco: India & China”, and global efforts like the Framework Convention for Tobacco Control, one hopes people will begin to realise the various consequences of the increasing global consumption of tobacco. Leena Patel, Medicine, UCL.

We want to know your views on global issues: please email your comments to medsinmagazine@gmail.com

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Neglected Tropical Diseases – Taking the N out of NTDs Laura Cordier highlights the global failure to eliminate tropical diseases and attempts to discover who is responsible

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ascioliasis and helmenthiasis are two of the littleknown tropical diseases that affect over one billion people worldwide, yet they have received very little attention and funding. Who is responsible for neglecting these diseases, and should we apportion blame to pharmaceutical companies, the international community, the media or ourselves? An Introduction to NTDs The World Health Organization (WHO) defines 15 diseases as neglected tropical diseases (NTDs) that persist nearly exclusively in poorer communities and have been largely eliminated, and thus forgotten, in wealthier countries.1 The 15 NTDs, as defined by the WHO are: Buruli Ulcer Chagas Disease Dengue Haemorrhagic Fever Dracunculiasis Fascioliasis Human African Trypanosomiasis Leishmaniasis Yaws

Leprosy Lymphatic Filariasis Neglected Zoonotic Diseases Onchocerciasis Schistosomiasis Soil Transmitted Helmenthiasis Trachoma

NTDs have significant economic effects in many developing countries. For example, the high prevalence of onchocerciasis (a parasitic disease caused by a worm, leading to blindness) amongst coffee plantation workers in Ethiopia reduces daily earnings by 10-15%3. Children are even more vulnerable to contracting NTDs leading to disruption of growth, education, and increased susceptibility to other chronic diseases. Despite the negative consequences, until very recently NTDs were not a global health priority and maintained a very low status in national and international public health agendas. A Mixture of Successes and Failures

Guinea worm is being eradicated. (Source: http://www.who.int/)

which has cured 14.5 million people of leprosy7. Another success story is the imminent eradication of dracunculiasis, commonly known as the Guinea worm disease and prevalent in Chad and Cameroon, using inexpensive implementation of water filters and vector control.8 Despite these efforts many NTDs remain ignored, and only six of the fifteen NTDs have been eradicated or controlled.9 Furthermore, even with the existence of low cost and effective interventions, the majority of affected people cannot access them10. Latin America has an extremely high prevalence of NTDs, which even supersedes the HIV/AIDS and malaria burden. For instance, nine million people suffer from chagas disease, with 50,000 new cases every year11. Chagas disease is caused by the parasite Trypanosoma cruzi, leading to cardiac and gastrointestinal complications. This condition can only be treated with Benznidazole or Nifurinox. However, both of these drugs are flawed, inefficient and difficult to access, as treatment requires admission into hospital, nursing care and intensive monitoring12.

Since 2003 there has been an increase in attention and monitoring of NTDs. The WHO has finally made it a priority, insisting on vector control, transmission reduction, and improving the quality of surveillance and care. “The task is feasible and must be done” says Dr Lorenzo Savioli, Director There are other cases that are more shocking and verge on of the Department of Control of Neglected Tropical Diseases the unethical. Human African Trypanosomiasis (HAT), also known as ‘sleeping sickness’, is a vector transmitted at the WHO.6 parasitic disease. It causes weakness, headaches (stage 1) Indeed, there have been a number of recent achievements. and ultimately leads to neurological disorders, coma and death (stage 2) 13. The only available treatments for this The most notable has been the release of affordable, safe, disease are Pentamadine for stage 1 and Melarsoprol for and easily administered drugs through multi-drug therapy,

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February 2009 - Issue 3 stage 2, both of which are extremely costly and hard to access. It has been estimated by the Centre for Disease Control and Prevention that the total cost of treatment by Pentamadine is €51.32 per patient and Melarsoprol €129.92 per patient, for a minimum of two weeks. Furthermore, Melarsoprol is an arsenic based drug, which is more than fifty years old; it is extremely painful for the patient and can itself cause death14.

Medsin UCL’s Global Health Magazine Science and the Media

The scientific community also has its role to play in the neglect of tropical diseases. Today scientific research is oriented towards financial profits and successful publications, rather than non-lucrative global health improvements.19 However, universities and other institutions are now being allocated funding for global health research No effective treatments have been developed recently for projects by organisations such as the Wellcome Trust and NTDs and very little research has been undertaken. Only 13 The Bill and Melinda Gates Foundation. This will hopefully help to discover effective new treatments for NTDs. of the 1223 drugs developed since 1975 have been for Tropical diseases are also largely neglected in the media. The media has a significant influence over society and it acts as an intermediary between organisations, governments, and the general public. It helps to raise international awareness of, and reaction to, particular issues. A group of journalists from the Guardian, the BBC, the Economist, and the Daily Telegraph were interviewed and asked to justify the lack of coverage on NTDs. They unanimously answered that there were no new developments and there is a limit to the amount of times one can report that tropical diseases are being neglected. The journalists concluded they are not responsible for the neglect of tropical diseases, but that the scientific community, and most importantly UN agencies, should speak louder.21 Child suffering from Chagas disease (Source : google.images.co.uk)

The Bottom-up Approach

Indeed, the action of the international community in the fight against NTDs has been insufficient. Western countries do not fund, and developing countries cannot fund, research and treatment of NTDs, and hence they remain neglected. Only recently have countries like the United States of The Power of Profits America started to invest in research, prevention, and control of tropical diseases; $350 million has been given In recent decades, international attention has been focused over five years to treat these diseases. However, the on HIV/AIDS, malaria and tuberculosis. They have received problem cannot be solved only by an increase in financial significant amounts of funding, especially through the Global resources. Fund, and have been at the centre of extensive research projects. This has not been the case for many tropical One way of addressing this situation sustainably would be to diseases, neglected by pharmaceutical companies, manufacture affordable drugs locally and involve the governments, and by the media. community. This bottom-up approach requires an improvement in local infrastructure and scientific capacity to Pharmaceutical companies have not created new increase the research and distribution of medicines.23 medication for NTDs, as it is seen as a “non lucrative Community empowerment and increased funding can market”. 17 Research and development is a long, complex collectively help to take the N out of NTDs. and expensive process, which requires a substantial amount of funding. The investment required by large pharmaceutical Laura Cordier is a 2nd year Human Scientist. She chose to companies does not match the potential profits to be made, write about this topic because she is particularly interested in the global fight against diseases. and so many tropical diseases remain neglected. NTDs.15 This all seems quite ironic considering the era we are said to live in; one of change, development, technology and solidarity.

The controversial aspect of this situation is that pharmaceutical companies regularly invest in drugs for Western markets. Josh Ruxin, a Columbia University expert on public health, points out that HIV/AIDS only truly became a cause for international attention and action when it hit the United States of America.18 This suggests a rather pessimistic future for NTDs as they are unlikely to affect the developed world on the same scale as developing countries. However, with increasing globalisation, tropical diseases may well become a global concern in the same way as tuberculosis and HIV/AIDS have.

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For more information: Visit http://www.who.int/neglected_diseases/en/ for additional information about NTDs Read Nature http://www.nature.com/nature/outlook/ neglecteddiseases/ Read “Tuberculosis: The Fight for Essential Medicines” on page 18 of this issue of ‘Perspectives’

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Preaching Prevention: The Importance of Understanding Local Knowledge Aadarsh Shah reflects on his visit to the village of Nyamuswa, Tanzania as part of the UCL Malaika Project. In particular, he analyses the local complexities of distributing insecticide-treated bed nets.

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here are no vaccines to prevent malaria. However, preventative measures such as insecticide treated bed nets, wearing long clothing at night and using mosquito repellents, such as sprays or coils, can be effective at reducing the transmission of the disease2. Early access to medical treatment can even treat the majority of cases. With viable preventative and treatment measures available for malaria, why is it that many countries such as Tanzania are still under threat? Are ignorance and unequal access to treatment adequate explanations for the high prevalence rates of malaria, or are there larger social and cultural issues at hand?

may have been better to work with the traditional beliefs of the community. By integrating our advice about prevention with the pre-existing ideas of the community, the advice may have seemed more rational and realistic to the people of Nyamuswa. The Impotency of ITN Distribution

However, aside from cultural differences, many people were totally uninformed on the value of preventative measures. When talking to a group of HIV positive people in the village, a group particularly vulnerable to malaria, they were unaware of the availability or purpose of insect repellents Malaria is “like having a cold” and coils. The previous year another group of UCL students had distributed insecticidetreated bed nets (ITNs) to The community that we worked homes in Nyamuswa. ITNs with in Nyamuswa largely are one of the most effective subscribed to traditional model of and well-documented explaining and dealing with methods of preventing illness. Community members transmission of malaria. often sought the advice of local Explaining the importance of traditional healers at the first sign ITNs, and the fact that they of illness. The biomedical, must be used every night and Western explanatory model of re-treated regularly, is just as illness was not so prevalent. important as distributing Villagers rarely used precautions them. It became clear that no against malaria, which was partly matter how effective the ITNs due to widespread cultural belief that it was “God’s will” if a person are in theory, in practice if people are not willing to use became ill, and therefore them, or are unaware of how preventative methods like bed to use them, then there is nets were useless. Another little point in distributing them reason cited for not using to everyone in sight. A more preventative measures was that holistic approach to ITN malaria was so common and likened to “having a cold”. distribution, which takes into (Source: Syngenta.com) account cultural beliefs and Therefore, despite the fact that local knowledge, is necessary to ensure that ITNs are an many friends and family die from malaria, the community effective preventative measure. does not consider it a serious issue and preventative measures are not considered a priority. For them, malaria is an everyday part of life that one only deals with once one is Waking up to the sound of funeral cries, I wondered if that death could have been saved with more holistic ITN affected themselves. distribution and better understanding of local cultural beliefs. Another common belief was that mosquitoes only bit people Aadarsh is a fourth year medical student at UCL who at certain times of the day and that malaria only affects certain people. It was frequently difficult to understand these participated in the UCL-led Malaika project aimed at improving preventative measures for malaria. ideas, as we were used to the biomedical model of understanding malaria, and therefore we felt the community For more information: beliefs were irrational. Subsequently we attempted to transform the community attitudes towards malaria. Using Get involved with Medsin UCL’s Malaria and Neglected the village drama group we were able to put on plays at the Sunday markets. The plays aimed to educate villagers about Diseases campaign by visiting http://www.uclmedsin.org/ malaria.htm the dangers of malaria, as well as promoting preventative measures. Although the plays were entertaining and informative, I was sceptical as to whether they would change For information about getting involved with The Malaika people’s attitudes towards malaria prevention. In hindsight, it Project visit http://www.malaikaproject.org/home.html

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February 2009 - Issue 3

Medsin UCL’s Global Health Magazine

Interview: The Importance of Partnerships Professor Michel Kazatchkine, Executive Director of the Global Fund for AIDS, Tuberculosis and Malaria, talks to Rachel Scott about the need for a partnership approach in global health. natural concept, it actually “took a long time to bring multidisciplinary teams Professor Kazatchkine, an established together”. The first time he was confronted with an interdisciplinary figure in immunology, first became approach was as Director of ANRS, involved in the public health aspect of evaluating the first experience of HIV/AIDS in the 1990’s, when he was access to antiretroviral drugs in four appointed director of the National pilot countries. The design of this Agency for AIDS Research (ANRS) in France. It was at this time, he says, that evaluation “tried to bring together “the world was realising, far too late of clinicians, sociologists, psychologists, epidemiologists, statisticians; and the course, the enormous global gap and result was very poor. It was very inequity between the north and the south”. In 2001, when the UN General difficult because people didn’t Assembly met to discuss AIDS, Professor Kazatchkine was part of the delegation of the French government that worked to design the Global Fund. He held a number of positions in the Global Fund, including chair of the technical review panel, French board member, and ultimately Executive Director. He explains that he “progressively transitioned from individual ethics to collective ethics, had an increasing interest in public health, and also learnt to realise that the future of health and development is really a political issue”. The Rise of Kazatchkine

“The Global Fund”, says Kazatchkine, “is specific in that its role is to finance initiatives”. The Fund launches calls for offers, receives requests which are reviewed by a panel of experts, and accepts the best proposals for funding. Money is then transferred to requesting countries for implementation of their own programmes. Professor Kazatchkine explains that the global fund is “responsive to country requests rather than deciding top-down where the money should go. Everything it approves is reviewed by an independent technical review panel and is very inclusive as a key principle; it represents civil society as well as the public and private sectors”.

Professor Kazatchkine (Source: UN.org)

understand each others languages”. It is still a slow process he says, giving the example of a recent meeting where although people were talking about the importance of involving the community and a multidisciplinary team, the most important thing at the end was still the success of the trial and the papers that came out of it, rather than the community where things happen.

Although he thinks there is a long way to go, he has a number of suggestions for improvement. “There is a need to learn from experience so that we can He is self-confessedly sceptical about the academic community’s response to adapt”, he says, “and a strong need to invest in new and innovative international health. When I ask him what he thinks of UCL’s interdisciplinary technologies for the future”. Most approach to global health he says that importantly, he believes that it is necessary to do this “with the although now it looks like almost a Work with the Developing World, for the Developing World

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developing world for the developing world”. This means a rethinking of the academic system, he believes, into a partnership and capacity building model. “Perhaps”, he says, “you need the humility of using two or three years time to build capacity somewhere and trust before you actually do something”. Advice for Students He has advice for students and graduates wanting to work in international health. Firstly, he advocates a strong academic background: “the legitimacy of everything we do in medicine is about the science, so you will be listened to as an individual if you can show that whatever you say is supported by evidence, and that whatever implementations you want to fund are evidence based”. Secondly, he stresses the importance of field experience, something that he himself regrets not having done extensively. “It is something that helps a lot because you learn how to interact with a community, a culture, and you also learn the reality of what vulnerable people need”. He strongly encourages young people to work in public health, emphasising “how extraordinarily challenging and rewarding it can be to deal with the health of groups and particularly with groups who have no voice”. Rachel Scott is a 3rd year Human Sciences undergraduate, interested in different perspectives on, and approaches to, international health and development. For more information: Full interview transcript can be read at http:// www.thelancetstudent.com/2008/12/04/ interview-with-prof-michel-kazatchkine/ Global Fund webpage: http:// www.theglobalfund.org/en/

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

The Failure to Eradicate Polio – is Nigeria to blame? The suspension of polio vaccines in Nigeria in 2003 has often been blamed for the global failure to eradicate polio. Emily Savell explains how the real story is much more complex.

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oliomyelitis (polio) is a highly infectious disease that mainly affects children under three years of age1. It is transmitted through contaminated food and water, and through the ingestion of faeces. The virus invades the nervous system, and although 90-95% of infections are subclinical (no visible symptoms), 1-2% of infections result in paralysis2. Mortality is rare, but when it does occur, it is often due to paralysis of the respiratory muscles. Due to the vast number of sub-clinical cases, the disease is very hard to control and monitor, as Heymann stated “for every clinically expressed paralysis there are at least two hundred children infected asymptomatically”3. Immunodeficient individuals, who cannot rid themselves of polio naturally, “can retain and spread the infection, in some cases for years” 4. The Global Polio Eradication Initiative

Resurgence of Polio in Nigeria Northern Nigeria’s decision to halt all polio vaccinations in 2003 is well documented. Religious leaders of this predominantly Muslim part of Nigeria raised unsubstantiated concerns that the vaccines contained substances which caused infertility, and were spreading HIV5, 6 as part of a secret Western campaign to reduce Muslim populations9, 10. These suspicions were reinforced by the chairman of the Supreme Council for Sharia in Nigeria, who blamed the “modern day Hitlers” for the contamination9. When the concerns reached the media, the northern Nigerian states’ governments decided to suspend all vaccines until they had been checked and verified. This should have been a quick process, but unfortunately a long twelve months passed until vaccines were reinstated. The damage had been done. Vaccination levels dropped, and by the end of 2004 the number of cases in Nigeria had almost doubled to 800 (from the record low of 483 cases in 20017), and polio originating from northern Nigeria reinfected other parts of the country, along with approximately twenty other countries which had previously been declared polio-free5. Some even go so far as to state that the suspension of vaccinations in northern Nigeria caused “more than 5000 additional paralysed children during 2003-2006”7. But what made Muslim leaders suspicious of the vaccines,

Oral polio vaccine being administered in Nigeria (Source: www.time.com)

The Global Polio Eradication Initiative (GPEI) was launched by national governments, UNICEF, and the World Health Organisation (WHO) in 1998, with the aim of eradicating polio by 2000, with an intense vaccination strategy. At that time there were an estimated 350,000 cases of polio worldwide in 125 countries5, 6. Although the initiative did not achieve its goal, by 2000 there were just 3,500 cases globally, equating to a 99% reduction1, and by 2007 there were only 1,3157. However, reporting bias is important because, as with all counts of disease, there is an element of underreporting and misreporting; and due to the high numbers of sub-clinical cases, polio is particularly prone to this. Although we think of polio as a disease of the developing world, it was not until June 2002 that Europe was certified as polio-free8.

Polio cases in 2004 (Source : www.polioeradication.org)

which they initially understood to be extremely beneficial to the population? Obadare11, who looked for the broader, underlying reasons for the situation, raises two main points. These were, firstly, the issue of distrust between the northern Nigerian Muslim population and the federal government of Nigeria since the return to civil rule in 1999, The GPEI has unquestionably been very successful, reducing cases at a rapid rate; but it has not been without its when the Muslim population became somewhat marginalised. And secondly, the distrust between Muslims problems. One of the most cited is Nigeria’s suspension of all vaccinations in 2003. Was that event the sole reason why and the West since the events of 11th September 2001 in the United States, where the establishment of a Western-led polio has still not been eradicated eight years after the ‘War on Terror’ made Muslims feel that they, and their GPEI’s initial target, or were there other problems the strategy faced? If eradication is ever going to be successful beliefs, were being targeted. As Obadare shows, Western we must understand all the possible problems, and only then organisations and pharmaceutical companies are seen as can an opinion be formed regarding the question ‘is Nigeria the front of American hegemony, which means the » Muslim population may suspect the WHO of having to blame?’.

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February 2009 - Issue 3 hidden motives. There were also different levels of trust within each household, for example, some only accepting vaccinations inside clinics, rather than those brought door-to -door9. Furthermore in Nigeria, suspicion of vaccination programmes actually began in 1996 when residents of one

Medsin UCL’s Global Health Magazine stimulate immunity as intended. VDP outbreaks have been seen in China, the Philippines, Madagascar, and Indonesia5, and in 2006, Nigeria suffered from the largest known VDP outbreak yet. Low vaccination coverage created perfect conditions for the virus to take hold and 69 cases of paralysis were reported in Nigeria in 200614. As Dr Olen Kew, from the Centres for Disease Control and Prevention states, the worry is how to explain to families that “it’s not the vaccination that is the real risk, but under-vaccination”16. Another VDP outbreak was reported in Nigeria early in 2008. When eradication is a lot closer, the OPV will be replaced with the more expensive and harder to administer (injection rather than oral) inactive polio vaccine, which would abolish the risk of VDP17. However, there is much debate in the literature as to when the switch should be made. What Now?

A Polio patient in Nigeria (Source:Picasa)

northern state accused Pfizer of testing experimental meningitis drugs on patients without fully outlining the risks9, 10 .

In the UK, all children receive an OPV at 2, 3 and 5 months old, and then boosters at ages 5 and 15. These types of strategies means that polio, in most developed countries, is now extremely rare or has been eradicated. However, in developing countries, because of the environment in which polio spreads (unhygienic conditions, contaminated water etc) the disease can take hold very rapidly, in a very susceptible population. Presently, polio is only endemic in four countries; Nigeria, India, Afghanistan, and Pakistan17, and catch-up vaccination programmes are currently taking place in these countries. During 2008, the far majority of polio cases occurred in Nigeria and India18, which are the two countries requiring the focus of eradication strategies in the coming years.

The issues surrounding polio eradication are multi-faceted and certainly not independent from one another. While it is easy to blame Nigeria for the current situation, as many Many therefore blame Nigeria for the cases of polio still people do, there are far more complex issues to be circulating a number of countries. Clearly the issues considered. Social, cultural, and political factors all play a surrounding the suspension of the vaccine in 2003 were important, but there were also other issues specific to polio part, as do other issues such as vaccine storage and the risk of VDP. In the next few years, more funding is needed to which had an impact. Unlike smallpox, polio has three help resolve the problems discussed and a renewed global strains rather than one, it has sub-clinical cases, and the effort is required to make sure the GPEI does not fail. The vaccine is much less potent, which when combined makes global eradication of polio has significant benefits for eradication much more challenging. There have been problems with the number of doses required to protect each international health and should be a global health priority, as child from polio, raising suspicions about the effectiveness of “until global eradication, no child is safe from polio” 1. the vaccine; and this has not been helped by reports of up to ten doses being given, and children still contracting polio12. Emily Savell is a Geography graduate, and is now a Masters student at UCL studying Social Epidemiology with a keen There have also been issues with vaccine storage; ideally interest in global health and in the spread of infectious vaccines need to be stored at cool temperatures to stop diseases. them losing potency and this is a problem in hot climates, where expensive storage systems are needed13. In addition, whereas polio transmission follows a seasonal pattern in temperate climates, in tropical climates transmission occurs For more information: all year round13. This makes eradication even more difficult as the pool of susceptibles is never sufficiently reduced by Visit the website for the Global Polio Eradication Initiative at vaccination to prevent the virus from circulating. www.polioeradication.org Problems Faced

In addition to these ongoing problems, another, perhaps even more serious, was discovered in Hispaniola in 200014; vaccine derived polio (VDP). The oral polio vaccine (OPV) contains live polio particles and is therefore genetically unstable and it can, in one in two-three million doses15, mutate and regain its ability to infect people rather than

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Visit the WHO website for up-to-date case numbers at www.who.int Read “A crisis of trust: history, politics, religion and the polio controversy in northern Nigeria” by Obadare (2005) in Patterns of Prejudice, 39 (3), 265-284.

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

How will the Financial Crisis affect Global Health? Maria Bartkiewicz comments on how the current financial crisis will affect the health and economies of developing countries

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s the global financial crisis continues to dominate the headlines, it seems that Western attention has moved away from the economic, social and health problems of the developing world. However, international organisations warn that it is the citizens of these countries who will bear the biggest burden of the crisis that originated in the financial centres of the developed world. It is undeniable that, following the global cutbacks in expenditure and consumption, the poorest people will be forced to compromise on basic necessities, such as food and health services.

If In Doubt, Cut Foreign Aid Income or Substitution effect? Developing countries are affected by the current worldwide recession in many interconnected ways. Trade, especially in natural resources, will slow down in line with lower global demand and a drop in production. Previous crises have resulted in increasing barriers to trade and new tariffs6. Remittances (migrant workers sending money back home to their family), which are the second largest source of cash in poorer countries6, will also decrease, due to an increase in unemployment in the developed countries and lower levels of migration4. Capital markets in developing countries

The health effects of the financial crisis are determined by the balance between the income effect, whereby contraction of GDP decreases capital available for health services, and the substitution effect, whereby reduced labour demand frees up people’s time for taking care of their health. In the developed world, past crises have generally been associated with better health and education. During the Great Depression in the USA, infant mortality fell and school enrolment increased7, 9.

In the developing world, however, where the baseline level of nutrition and healthcare is already low, the income Previous crises have effect is generally observed to dominate, although school enrolment resulted in increasing sometimes increase. The World barriers to trade and new does Bank estimated from demographic and health surveys carried out in 59 tariffs countries between 1986 and 2004, that a 1% contraction in GDP per capita was associated with an increase in infant are typically more volatile than in mortality between 0.18 and 0.44 per developed countries, so foreign direct thousand children born9. There is a investments to these countries, which considerable level of regional variation are so important for GDP growth, will decrease. As a result, economic growth in effects; for instance in Peru the economic crisis of 1980 helped in developing countries will be lower increase the relatively high school than in previous years. enrolment levels but infant mortality Levels of foreign aid may be reduced as also increased by 2.5%7. While businesses can be rebuilt, the foreign aid is strongly procyclical world cannot afford to allow the global (positively correlated to the overall state The Problem of Food Security recession to adversely impact the of donor countries’ economy). The health of its citizens. Reduced Arguably, the most serious ramifications International Monetary Fund (IMF) investment in health not only causes of the financial crisis will be brought unacceptable human suffering, but also analysed three periods of recession, about by its effect on food security. has long-term consequences for quality 1990–93, 1997–98 and 2001 to There are two aspects to the problem: of life and the economic productivity of present, and found that during every agricultural productivity and food prices. recession studied the total amount of societies. official development assistance (ODA) The current financial crisis comes immediately after the food crisis - a In recent decades, the world’s poorest from developed countries declined. At the UN Doha Conference in December period of extremely high food prices, people have increasingly become 2008 the UN Secretary General Ban Ki brought about by market speculation on intertwined in the formal global food prices, population growth, Moon urged governments to maintain economy. As urbanisation increases, their aid commitments, asking “Are we subsidised bio fuel production, and many more people depend on wage limited food production, owing to under labour for their livelihood, making them to ‘economise’ on ODA, worth some more vulnerable to global price shocks2. hundred billion dollars, while trillions are investment in agriculture2. As food mobilised in the rich countries to fight prices dropped last summer, the food their financial problems?”10 crisis has fallen off the international media radar, but the situation is not The current financial downturn comes after a prolonged and intense period of growth in the global South; developing countries in Asia and Africa grew on average 9% and 6% respectively from 2005 to 20072. Gross Domestic Product (GDP) growth within developing countries is predicted to fall from 7.9% in 2007 to 4.5% in 20097. The World Bank estimates that every additional percentage point of GDP growth reduces the proportion of people living on less than $1 a day by about 2%4. The sudden stagnation in GDP is therefore a shock that could cause a reverse of the recent progress in development indicators.

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February 2009 - Issue 3

Medsin UCL’s Global Health Magazine

are felt long after the crisis is over, even if there is an improvement in nutrition. Adults who were undernourished in utero have a higher chance of High food prices should have, in theory, developing the metabolic syndrome, and girls undernourished at an early provided an impetus for investment in agriculture, which is urgently needed in age develop cephalo-pelvic disproportion, which increases the the developing world. However The likelihood of maternal and perinatal International Food Policy Research death. A 2008 study showed that men Institute (IFPRI) asserted that developing countries lagged behind the who were undernourished as children earned 50% lower wages than their developed world in agricultural peers who benefited from adequate expansion; for instance, the Food and Agricultural Organisation estimated that childhood nutrition intervention5. Investment in a healthy population can between 2007 and 2008 cereal output help economic recovery and prevent increased by 11% in developed the vicious circle of poverty and ill countries, but only by 0.9% in health2. developing countries2. media radar, but the situation is not likely to get better for the developing countries.

The unfolding financial downturn could reverse the, albeit limited, positive effects of the food prices bubble and lead to lower investment in agriculture in the developing world, particularly in foreign direct investment, crucial for GDP growth. Demand for food is predicted to decrease in line with slower population growth, but bio fuel demand for crops is expected to increase substantially, and if contracts are not negotiated fairly this could exacerbate food insecurity6.

“Economic shocks also elevate levels of psychological distress

conference, representatives urged states to ensure that they meet their aid pledges of 0.7% of total GDP19. Margaret Chan, the Director-General of WHO, urged increased investment in health and social sectors in face of economic downturn, in order to protect the poor and to promote economic recovery and social stability3. The picture is a lot more complex than simply raising awareness and philanthropy, however7. IFPRI suggested that if agricultural productivity and investments can be maintained under recession, the consequences for malnutrition and health could be reduced. Many experts suggest policies to ensure stability of food prices, for instance, the Institute for Agriculture and Trade policy (IATP) advocated an establishment of speculative position limits for key commodities2.

The financial crisis is likely to push millions of extra people into poverty, while weaker growth and tight credit Economic shocks also elevate levels of conditions will leave governments with a decreased capacity to improve psychological distress more than the welfare programmes to help these impact of sustained poverty would people. The overall outcome of the suggest. A study in Indonesia showed crisis will be determined by a complex that elevated levels of distress No time to waste interaction of offsetting factors (as persisted long after the economy had recovered from the 1997 financial crisis exemplified by interplay between income and substitution effect) and and household consumption had Rising food prices, combined with policy responses, and will be very returned to pre-crisis levels7. deteriorating purchasing power and difficult to predict. While politicians and diminishing demand for developing What can be done? economists brainstorm the ways to get world produce, will have major the global economy out of the crisis, implications for global health. Lowthey must be aware that the well being income families spend 50-70% of their The solution to such a complex of vulnerable populations in developing financial crisis will not be easy. There income on food2. As food prices rise countries is now more likely to be at risk will be inevitable trade-offs between these vulnerable populations will be than ever before. short-term responses (for forced to limit food consumption and macroeconomic stabilisation) and more shift to cheaper, less nutritious diets. Maria Bartkiewicz is a third year Human long-term goals of restoring economic Accessing health and education Sciences student at UCL and is services will be another challenge in the growth and development. interested in the economic influences face of increasing poverty. The effects Nonetheless, in order to preclude the are grave; in Bangladesh, for instance, long-term consequences of even short- on health. a 50% increase in the price of food has term underinvestment in health and nutrition, social protection must be increased the prevalence of iron For more information: deficiency among women and children expanded to mitigate the risks. As poor 1 countries’ revenues decrease because by 25% . IFPRI estimates that under Attend lecture “Will the Rich Man’s the most likely recession scenario, per of reduced demand for exports and Crisis Crush the Emerging EconoFDI, they will depend heavily on aid to capita calorie consumption in Africa mies?” on Tuesday 10th March at 6.30 provide such security. It is vital that would decrease by 10% by 2020, and p.m. in the Sheikh Zayed Theatre, globally 16 million more children would donor countries maintain sufficient aid LSE. For more information visit flow to meet healthcare provision and be malnourished2. www.lse.ac.uk/events/ food security needs in developing countries. IFPRI has suggested that Many studies have shown that both Read “Global Economic Prospects – protective and preventative programs protein and micronutrient deficiencies Commodities at the Crossroads 2009” such as school feeding should be have long-term, detrimental effects on by The International Bank for Recon2 health. For instance, child and maternal strengthened . struction and Development/The World deaths increase and general immunity Bank (2009) In the final statement of the Doha is compromised. The consequences

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Women in Sub-Saharan Africa: Can they say No to HIV?

Anastasia Hadjivassiliou argues for the importance of implementing gender-sensitive HIV/AIDS policies in Sub-Saharan Africa

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n the last few decades HIV/AIDS has been the topic of abundant discussions worldwide. Despite persistent efforts globally to reduce HIV transmission, infections still continue to rise. The World Health Organisation (WHO) reported in 2007 that approximately 33 million adults were living with HIV worldwide and 60% are found in SubSaharan Africa, out of which two thirds are women. These figures suggest that women are at a higher risk of HIV infection1. The question is what are the causes of this apparent higher risk and what can be done to redress the balance? Global campaigns have tried to promote three important strategies; abstinence, monogamous relationships and the correct use of condoms. Measures like these depend on the important assumption that individuals have the power to make decisions about their sexual activity. However, studies have shown that a woman’s ability to control her sexual behaviours directly opposes established gender inequalities in SubSaharan Africa, as determined by socioeconomic and cultural factors.

out of necessity to pay for food or education2. There are also significant gender inequalities when it comes to sexual negotiations. Therefore, even though

some strategies strongly advise condom use, it may not be feasible for women to demand this, since such decisions mainly depend on the male partner. Furthermore, as stated in the United Nations General Assembly Special Session Country Progress Report in 2008, young girls were less likely to have knowledge of HIV transmission compared with their male peers1.

Another obstacle preventing women from negotiating condom use is fear of their partner’s reaction. This could potentially result in violence or Due to gender inequalities, women in abandonment, thus placing women in a some regions of Sub-Saharan Africa, difficult financial and social situation. more so than their male counterparts, Alternatively, men may consider that are affected by poverty and a lack of their fidelity is being questioned or that education. These factors heavily influence the susceptibility of women to the woman is sleeping with other men. In addition, violence increases women’s HIV infection. Many women do not vulnerability through coercive sexual receive formal education owing to financial difficulties which force families intercourse. A study in Uganda showed that women who reported coerced first to limit education to sons. In some cases education is intentionally withheld intercourse were less likely to use current methods of contraception in to keep girls at home for domestic their last intercourse, or be consistent in duties. Occasionally, education is condom use in the preceding six considered a waste of resources months4. because women get married and subsequently leave the family. This lack Empower, Educate and Elevate of education means women are often Women financially dependent on their male partners. With limited economic prospects, some women may be forced For the last ten years it has been actively recognised that gender to engage in risky sexual behaviours Living in the Shadow of Men

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inequalities must be integrated into the strategies for HIV prevention. Empowering women through education and transforming gender relations is fundamental for an effective decrease in HIV transmission to occur. As stated in the WHO ‘So What’ report, campaigns that incorporated these issues in their strategies have had positive results in Mexico, Brazil, Thailand and India. In addition, a study in South Africa revealed that girls who were educated became sexually active at a later age, were more likely to use condoms, less likely to engage in risky sexual behaviours, and experienced lower levels of coercive intercourse5. The Joint United Nations Programme on HIV/AIDS has also reported that women in the highest social class quartiles had more information regarding HIV testing services, compared with women in the lowest quartile6. It is important to remember that HIV/ AIDS is not exclusively a problem of the Sub-Saharan countries, and improvement in women’s rights must be a globally united effort. As stated by Pnina Herzog, President of International Council of Women in 1999, “Disease knows no geographical borders or class distinction. Whatever affects certain populations very soon affects us all”. Anastasia Hadjivassiliou is a 4th year medical student at UCL and has a particular interest in women’s global health issues.

For more information: Get involved with the Medsin UCL Student Stop AIDS Campaign by visiting www.uclmedsin.org/stopaids.htm Visit www.unaids.org to read the UNAIDS Report 2008 Visit www.unfpa.org/hiv/women/report/ to read ‘Women and HIV/AIDS: Confronting the crisis’

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February 2009 - Issue 3

Medsin UCL’s Global Health Magazine

Vaccines, Dubious Drugs and Malaria

Alisha Allana explains how counterfeit drugs and a new vaccine may shape the future of the malaria epidemic

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alaria is often described as one of the world’s biggest killers.1 Indeed, despite advances in medicine, about 400 million people contract the disease every year with a large proportion dying as a result2. By examining the causes of death, and more importantly, the underlying factors such as poor health care and hygiene, it may be possible to better control malaria and prevent death.

problem is that most medical centres in the developing world do not have access to the laboratories needed to test for the authenticity of the medication, and so often neither the patients nor the doctors know whether the treatment will work effectively.

While many companies produce counterfeit drugs without any active substances, others contain a tiny percentage of A Deadly Combination the real medicine, which contributes to another growing concern; an increase in cases of multi drug-resistant malaria. Another common reason for malarial drug In Africa a particular problem is co-infection with both malaria and HIV. This increases the death rate significantly, resistance is overuse of drugs. Laboratories in the developing world are not always able to accurately diagnose as HIV-positive individuals are more likely to develop the serious symptoms of malaria3. Co-infection, coupled with the malaria and so physicians tend to over diagnose it and over prescribe medication, leading to drug resistance. This general effects of the malaria epidemic, have given rise to social and economical problems that are likely to worsen in resistance makes the treatment of malaria more difficult with existing drugs, leading to unnecessary and avoidable the foreseeable future. Poverty is an important cause and effect of malaria. The majority of countries where malaria is deaths. prevalent cannot afford to effectively prevent or treat the disease. Vaccine Provides Hope on the Horizon Malaria disproportionately, and more severely, affects However, there is new hope for the future in the form of a children and contributes to a significant dropout rate from vaccine that could effectively prevent the transmission and primary education. The burden of disease also affects spread of malaria. Recent trials in Kenya and Tanzania have government spending, with a disproportionately large amount of the budget required for health services, potentially demonstrated that the development of the vaccine could forcing reductions in other sectors such as infrastructure and decrease infection rates greatly.7 Despite these advances, the cost of research is very high, hence the need to promote tourism. the use of existing anti-malarial treatment in order to minimise the devastating effects of the disease. Preventative measures such as ensuring pregnant women and children sleep under DEET-impregnated mosquito nets, and prescribing pregnant women anti-malarial drugs to protect their unborn children, could improve the situation greatly. Prevention of future cases and treatment of existing cases must be promoted in equal measure to bring an end to the global malaria epidemic. Alisha Allana is a first year medical student at UCL and is interested in promoting health issues, particularly in developing countries.

Drug Deception For more information: Counterfeiting of malaria drugs has led to a steep increase in the number of preventable malaria-related deaths, particularly among children. Up to 70% of malarial drugs in central Africa are not genuine4. The problem has not been greatly publicised, for fear that sales of genuine drugs would decrease as a result. Yet, thanks to the production of fake medications, malaria is a more serious problem than it would otherwise be. According to the World Health Organization, “200,000 of the one million malaria deaths every year would be prevented if all the drugs taken were genuine”5. The

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Get involved with Medsin UCL’s ‘Malaria and Neglected Diseases’ campaign at http://www.uclmedsin.org/ malaria.htm Read ‘Biomedicine and the Human Condition’ by Michael Sargent Read ‘The Fever Trail’ by Mark Honigsbaum

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Tuberculosis: the fight for essential medicines Katherine Pitt discusses the lack of research and funding for tuberculosis and explains how Médecins Sans Frontières (MSF) are redressing the balance very second, someone in the world contracts tuberculosis. Every day, 25,000 people develop active infection.1 Every year two million people are 2 killed. Today, tuberculosis kills more people than any other curable infectious disease in the world.1

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Thirdly, and most importantly, tuberculosis is most prevalent in developing countries where patients cannot afford expensive new treatments. Therefore research and development of new tuberculosis drugs would not be a profitable endeavour for the pharmaceutical industry.10

Outdated Medical Treatments

A Disease of Poverty and Neglect Tuberculosis is linked to deprivation, mostly affecting the poor and contributing to destitution. In the developed world, the disease is concentrated in marginalised groups; homeless people, drug users, HIV patients, prisoners, and new immigrants.11 However, 95% of cases and 98% of tuberculosis deaths occur in the developing world.1 Tuberculosis predominantly affects economically active adults, and therefore a case of tuberculosis is estimated to reduce household income by 25%, and the death of an adult amounts to fifteen years of lost income.12 The international response has been feeble. Médecins Sans Frontières (MSF) classified tuberculosis as one of the top ten neglected humanitarian crises of 2007.13 The epidemic throws into question our commitment to society’s most vulnerable. The issue is not simply one of public health, but of social justice.

The medical tools used to fight tuberculosis are antiquated. The diagnostic methods currently in use are the same as those used in the late nineteenth century, when the disease agent was first discovered.2 The BCG vaccine is nearly a century old and the drug regimen, developed in the 1950s and 1960s, has not since been advanced.3, 4 As treatments for many diseases have progressed at a startling rate, research and development for tuberculosis drugs has remained stagnant.

Tuberculosis funding reflects a wider global imbalance. Just 10% of research money is spent on diseases causing 90% of the world’s health burden.9 Other diseases neglected relative to human need are malaria, Chagas’ disease, schistosomiasis and leishmaniasis. Just 1% of drugs that have come to market over the past thirty years were developed for a neglected disease.15 MSF Campaign for Access to Essential Medicines

The outdated resources used to tackle this crisis are inadequate. Diagnostic methods only identify 45 – 60% of people with active tuberculosis, and the BCG vaccine only offers limited protection. In addition, the treatment regime is plagued by side effects, leading to low drug adherence rates5, 6. HIV co-infection, found in up to 75% of cases, makes tuberculosis even harder to diagnose and treat.7 There are 500,000 new cases of multi-drug resistant tuberculosis identified each year and this is another problem which highlights the need for new medication.8 Where is the Research and Development? Why has research and development been so badly neglected? Firstly, successful tuberculosis elimination programmes were scaled back in the late twentieth century. The elimination of tuberculosis seemed certain just 25 years ago, but the epidemic re-emerged, riding on the back of the HIV crisis.9 Secondly, the World Health Organisation’s (WHO) recommended strategy, DOTS (Directly Observed Treatment Short-Course), is based on the deployment of current treatments, not the development of new ones.5

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In 1999, MSF launched the Campaign for Access to Essential Medicines. Their advocacy has three goals: overcoming access barriers, challenging trade restrictions and stimulating new research into neglected diseases.16

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February 2009 - Issue 3 Progress is encouraging and Richard Horton, editor of the Lancet, has argued that “organizations such as MSF have replaced WHO at the leading edge of policy development” 9. Several product development partnerships have been established through the Drugs for Neglected Diseases Initiative and the Doha declaration, which enabled flexibilities on the Trade-Related Aspects of Intellectual Property Rights (TRIPS). In theory the flexibilities help developing countries access patented drugs at cheaper prices, though in practice the flexibilities are misunderstood and under-utilised by many developing countries10. There still remains much work to be done in improving the access to essential medicines for all, however the work of MSF and the Doha declaration provide hope.

Medsin UCL’s Global Health Magazine For more information: Join the Friends of MSF, the UCL-based group committed to raising funds for and awareness of MSF. (email: uclmsf@googlemail.com, website: http://www.msf.org.uk/ ucl.friend) Read: “An imperfect offering: dispatches from the medical frontline” by James Orbinski (see review in issue 2 of ‘Perspectives’) Read: http://www.msfaccess.org/main/tuberculosis/

Kate is a first year medical student and human sciences graduate, interested by health inequalities.

What’s Going on...

By Maria Bartkiewicz

Medsin UCL sends out weekly newsletters to inform students of the latest global health events. To join our mailing list please visit www.uclmedsin.org

February

April

Who Owns Fairtrade? A debate on who benefits, influences and controls Fairtrade

World Health Day

Tuesday 24th 6.30 - 8pm Hong Kong Theatre, LSE The idea of fair trade has become increasingly popular amongst consumers and some producers. But who does fair-trade really benefit? The producers, the consumers or the farmers? This event is free. Visit www.lse.ac.uk/events for details

Mexican Social Policy: toward achieving the Millennium Development Goals Wednesday 25th 6.30pm New Theatre, LSE

Tuesday 7th

The latest Chinese healthcare reform: How to handle 1.3 billion people’s healthcare LSESU China Development Society seminar Wednesday 29th 2.00-3.00 pm, D402, Clement House, LSE Professor Wang Hufeng, an expert on healthcare reform, analyses China’s healthcare system The event is free. Visit www.lse.ac.uk/events/ for details

May UCL Global Health Institute Symposium

Join us for a lecture and discussion with Dr. Gonzalo Hernández Licona on the progress of Mexico toward meeting its development goals. Visit www.lse.ac.uk/events/ for details

March UCL Global Health Institute Symposium Wednesday 11 4.30- 6.00 pm Details to be confirmed soon. See www.ucl.ac.uk/global-health/ events th

Global TB Day Tuesday 24th

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Wednesday 13th 4.30-6.00 pm Details to be confirmed soon. See www.ucl.ac.uk/globalhealth/events

The Human Right to Health Conference Thursday 14th – Friday 15th A two day conference hosted by the Centre for Philosophy, Justice and Health, in association with the UCL Institute for Global Health, UCL Institute for Human Rights and The Lancet. Details will be available shortly at www.ucl.ac.uk/cpjh

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Reviews Death without Weeping: The Violence of Everyday Life in Brazil By Nancy Scheper-Hughes, Published by University of California Press June 1992. Nancy Scheper-Hughes started out as a young volunteer in the Peace Corps in the 1960s. It was within this voluntary capacity that she first came into contact with the women in the sugar-growing region of northeast Brazil. Having been touched by the deprived and often frayed lives of these families, ScheperHughes returned to the area in the 1980s as a curious, well wishing anthropologist fascinated by the ways and means that the women of the community had adopted in order to cope with the difficult conditions in which they lived. With hunger, disease and lack of education effectively dictating the shape of these people’s lives, it is hard not to appreciate the need and desire for this successful anthropologist to bring the story of this deprived region of Brazil to our attention. However bad our own economic crisis is, it is not often in this day and age, that one comes across an anthropological study of a population in the free world who have less to eat in a day than prisoners once did in the Buchenwald concentration camp; Death without Weeping is just such a study. Economic exploitation of certain areas of northeast Brazil has transformed this resource-rich and beautiful region into one dominated by poverty, disease and death, and one in which starvation appears to be the order of the day.

child is testimony to the impossible and heartbreaking circumstances these women find themselves in.

Infant mortality is a major focus for Scheper-Hughes throughout the book, having been shocked by the high death rates, and even more so by the seemingly irrational attitude of mothers to these infant deaths. Such is the situation in this area of Brazil, and the astonishing number of children who become “little angels” (a euphemism for children who have died), it is not unusual to find mothers who neglect their weak, under-sized or lethargic babies in the belief that they would be a waste of time. “And so a good part of learning how to mother …includes knowing when to let go of a child who shows that he wants to die”. The almost coldblooded lack of grief, shock or sadness following the death of ones

The key message of this book is that Scheper-Hughes identifies the mothers’ thoughts and behaviours, not as being irrational, but as necessary and logical. A child born here is destined to grow up in the slums where they will need to survive disease, illness and starvation, and if they are born weak or ill they will simply not survive. Mothers avoid attachment to their new-borns so that if, as is very likely, their child dies soon after birth, their grief does not disable them. The strength of this book is that it explains how this irrational and unnatural behaviour of mothers is actually wholly rational and pragmatic. Overall, this magnificent book documents a hidden world, shaped by western economic demand, lack of education, poverty and malnutrition. Death Without Weeping has been undeservedly overlooked, due to its substantial size and academic orientation. However it is a vivid and detailed account of the everyday structural violence which plagues the poorest communities of north-eastern Brazil. Those who choose to navigate through this substantial book will not be disappointed. Lucy Reeve

INVISIBLES: A film with five true stories depicting forgotten crises Produced by Javier Bardem with the support of Médecins Sans Frontières (MSF). The Invisibles are those we do not want to see, but who end up appearing inside our fears and thoughts, because they never stop existing. Invisibles is inspired by MSF’s work with neglected humanitarian crises. A different acclaimed director has worked on each of the five constituent short films which make up Invisibles (namely Invisible Crimes, Voices of the Stones, Letters to Nora, Goodnight Ouma and Bianca’s

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February 2009 - Issue 3 Dream). The summation of these shorts into the final film brings to centre stage the victims whose plight we do not see or we try to forget. The creativity of the directors reinforces the core theme of the film. The first film Invisible Crimes addresses the problem of sexual violence in the Democratic Republic of Congo. As women recount stories of brutal rape, they fade in and out of view, silenced by circumstance.

Medsin UCL’s Global Health Magazine “1800 weight-loss medicines have patents pending”. While used sparingly, shocking imagery demonstrates poignantly the horrors encountered. This is particularly true of the child soldiers in Good night, Ouma.

Although principally a documentary film, role play is occasionally used to portray specific situations. In Bianca’s Dream, campaigners interview a pharmaceutical company CEO about eflornithine. The drug’s manufacture as a By focusing on human stories, the directors capitalise on our treatment for sleeping sickness ceased in 1995 because the empathy with individuals. Voices of the stones recounts the developing world market was unprofitable. When it was experiences of families displaced by ongoing violence in discovered that eflornithine had a lucrative cosmetic Colombia. application, production resumed. The case for change is reinforced by hard facts. Letters to Nora examines the impact of the parasitic Chagas disease. Onscreen the viewer is told, “no laboratory in the world is researching to develop a cure for Chagas disease”, and yet

Invisibles is a beautifully executed film relevant to all those interested in humanitarianism. Katherine Pitt

The Devil Came on Horseback: Film screening by Medsin UCL Directed by Ricki Stern and Anne Sundberg. A powerful and poignant piece of cinematography that will provoke many thoughts and questions. The feature length documentary follows Brian Steidle, a retired US marine, on his first job outside of the military as a patrol leader monitoring the ceasefire in Sudan in early 2004, between the mainly Arab Islamic north and African Christian south. He explains the recent history of the conflict in Darfur, including how the 2004 ceasefire did not consider the welfare of the Africans in the western region of Darfur. This led to the formation of two African rebel groups, the SLA (Sudan Liberation Army) and JEM (Justice and Equality Movement), who wanted economic development and education for the people of Darfur. In response to this, the Arab-dominated Sudanese government in Khartoum, who rule by intimidation, allegedly sent in the Janjaweed. The Janjaweed are a group of Arab militia, trained and funded by the government, who pillage, burn, torture, rape and obliterate entire villages in Darfur – the ‘Devils on Horseback’. This has caused a humanitarian disaster, both as a direct result of the Janjaweed’s actions, and as a result of the mass refugee flows. These refugees have fled to overcrowded camps in Chad, with little access to essential resources such as water and firewood. Brian Steidle spent six months taking pictures of all the atrocities he saw, of burnt victims who had been chained, babies shot through the back and entire villages burnt to the ground and for what? Because they’re African. In his words, Brian Steidle witnessed a genocide. He left after the frustration of not being able to do anything became overwhelming, and he tried to return to a normal life back in the US, but the memories were too strong. He published his pictures in the New York times and soon became a focus for talk shows and politicians. He ignored requests by politicians to keep quiet and spoke out about what he had witnessed. The word ‘genocide’ was becoming harder and harder to avoid.

this gives viewers a first-hand insight into the conflict in Darfur. Brian Stiedl set out to monitor the situation in Darfur with impartial eyes; yet he found, and as viewers will no doubt discover for themselves, that it is near impossible to remain objective once one opens their eyes to what is happening in Darfur.

Brian’s images are shown throughout the documentary and

Elena Ferran

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Medsin UCL’s Global Health Magazine

February 2009 - Issue 3

Fun Facts and Light Relief By Natasha Lyons The Magic of Mould Centuries before the “discovery” of penicillin in the late 1920’s, folk medicine had long been experimenting with the damp side of two-day-old toast. Reports of the use of mouldy bread and milk scrapings to treat wounded soldiers emerged from sixteenth century Greece, while tales of the antiseptic powers of mouldy soya beans in China are dated to three thousand years ago. Ancient Egyptians of 1500BC also left records testifying to the curative nature of various moulds, including their ability to cure boils. So turn up the humidity, leave the Christmas fruit exactly where it is and watch the magic of nature’s remedial rot unfold in your own home. Perfect DIY for a season when A&E is just too crowded…

Pandemic Pandemonium Match the titles of the world’s deadliest disease outbreaks with the estimated death toll over the time period stated:

The Great Influenza (“Spanish Flu”) 1918 - 1919 The Black Death 1300 – 1400 and 1700

4 million deaths per year

10,000 per day

The Plague of Justinian Mediterranean, 541AD

100 million in six months

Acute respiratory infection Present-day

100 million in total

The seventh Cholera pandemic 1961 to present

9,000 in total

Answers: Great Influenza – 100million in six months; Black Death – 100million in total (that is, over two hundred years); Plague of Justinian – 10,000 per day for two months (thought to be a bubonic plague); Acute respiratory infection – 4million deaths per year; the seventh cholera pandemic – 9,000 in total.

Empire Elixir Which three of these present day features and practices of modern medicine were initiated in ancient Rome? A) Prescriptions B) Illegible hand-writing C) Abortion D) Compulsory short fingernails for practitioners E) The Syringe F) Antibiotics G) House-calls

Answers: A), D), G) (Source: Telegraph.co.uk)

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February 2009 - Issue 3

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Medsin UCL’s Global Health Magazine

Medsin UCL is a society dedicated to tackling global health issues from around the globe, and Perspectives Magazine is just one of the many things that we do.

We run Campaigns on a whole range of issues, from Malaria and HIV/ AIDS, to Climate Change and Water & Hygiene. We work everywhere from the street corner with a petition, to the Houses of Parliament with our MPs—its your choice! In our Projects you’ll get to actively work with the community, from as near as Inner City London to as far afield as Ghana, and on health issues from sex education to bone marrow registry. In the end, what you do is completely up to you. Why not explore Global Health with Medsin UCL? You never know where it’ll take you!

Take a closer look at Medsin UCL and sign up to our newsletter at www.uclmedsin.org, and email us, even just to say hello, at medsin.ucl@gmail.com. 24

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Issue 3 - UCL Medsin Perspectives Magazine  

This is the third and final issue of Perspectives for this academic year. This issue focuses on neglected diseases, with articles on the fai...