UCLU Medsin’s RUMS Society’s Global Health Magazine
Rape of Darfur
Should we be worried? Interview with
Dr. Chikwe Ihekweazu
Published on behalf of UCLU Medsin RUMS by Zaneta Forson & Efuntunde Akerele
Letter from the Editor Hi my name is Adaugo (Diggi) Amajuoyi and I am the Chief Editor of Perspectives, UCL Medsin Global Health Magazine for 2009-2010. I aim to keep you informed with articles on various global health issues and UCL Medsin related events. In this issue we examine the basic idea of global health, debate the effect of the recession on our health, and discuss the hot topic of Swine Flu. We also interview Dr Chikwe Ihekweazu, Physician, Epidemiologist, Co-founder of the Nigerian Public Health Foundation and serial blogger. With the upcoming UCL MSF Darfur Week (30th November- 4th December), our feature article raises the awareness of the crisis in Darfur. After reading this magazine if you find yourself inspired and interested in getting involved in the next issue of Perspectives, send an email to firstname.lastname@example.org. As you can imagine there are several ways of taking part, the magazine needs writers, editors, fundraisers, proof readers and photographers. Remember no previous experience is required, just enthusiasm! For more information about UCL Medsin Campaigns and Events please visit www.uclmedsin.org
Letter from the Presidents Hello Everyone! We’re Zettie and Efun, your new co-presidents for the upcoming year. This is just a quick message to tell you a bit about what Medsin is and what we are hoping to accomplish in the year ahead. MEDSIN UCL is a branch of a network of students all around the world who have a personal interest in and passion to see global health problems solved. This year we’re describing Medsin as ACE!
ALL INCLUSIVE This year we want to encourage non-medics and medics involved in Medsin. It’s not just for medical students so everyone please feel free to come along and be involved in the diverse activities we have going on. CAMPAIGNING FOR CHANGE We run many projects and campaigns with diverse areas of focus and for everyone to get involved. Our projects include teaching young students about sexual health in the community (sexpressions) and skip which raises money and helps build schools for children in Ghana. The campaigns range from Universities Allied for Essential Medicines, Save our NHS to Healthy Planet. This year we have a new GENDER EQUITY campaign being launched and all are welcome to join in starting it up!
ENGAGING AND EDUCATING STUDENTS Listen out for speakers, debates and film screenings! A big part of Medsin is giving students the opportunity to learn more about global health issues that interest them and these are a great way of starting that off. It’s also a way for you to find and begin an interest in new topics! This year we also have new events such as Country Evenings, which promise to be fun and dynamic evenings full of both culture and health. Medsin will be collaborating with various cultural societies throughout the year to engage both sides of the story. Look out for posters and adverts! Overall this year we hope to expand Medsin to involve more and a wider variety of students and collaborate with other societies and student groups to give a more accurate representation of the diversity of issues involved in global health. We hope to see you at our events and that you do get involved, there is a lot to do! Remember ....Medsin is ACE!
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Global Health: Decisions, decisions
Born in the USA Health Reform Change We Can Believe
Rape in Darfur
If You Contract AIDS, You Will Die
16 Dr. Chikwe Ihekweazu 18 Binge Britain 21
20 A Decent Proposal 21 Recession Depression 22 Roma Gypsies 24 Reviews 26 Cover photo from: www.unrefugees. org.au/PDF/3darfur-womenmanjuracamp.jpg
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The Team Chief Editor Core Editors Head Designer Cover Photo Proof Reader Fundraiser Webmaster
Adaugo (Diggi) Amajuoyi Lucy Reeve Katherine Pitt Katherine Law Adaudo Anyiam-Osigwe Zarus Cenac Shagufta Fayguz Lauren Hookham Chibuzo Mowete Katherine Pitt Lucy Bradbeer Katherine Law Joel Cunningham
Current Affairs Assisted Suicide After much debate and fanfare, the government published a ‘clarification’ of the laws involving helping a relative commit suicide, however, this new guidance does not mean that any laws have been changed. It states that “there are no guarantees against prosecution”, and cases will be assessed individually. Assisting suicide is still illegal, and can carry a jail sentence of up to 14 years. The factors that will be taken into account include; if there is pecuniary benefit for the assistant, the age and prognosis of the patient, and how the decision to commit suicide was reached. Over the past decade, over 100 Britons have with terminal or incurable illnesses have taken their own lives in the Dignitas clinic in Switzerland, and none of their relatives have ever been prosecuted. While the furore over the Swiss Dignitas clinic has been making the headlines in the UK, it is worth comparing the statistics with those of other countries. Even in Dignitas, British patients are outnumbered 5 to 1 by Germans; and in the Netherlands, where the doctor-assisted suicide is legal, 2,300 people per year choose when to die. In the USA, only a few States have legalised assisted suicide, although political and public opinion has shifted slightly as the global debate has reignited. Joshua Balkin 2nd year Human Sciences student
Seven Steps to Saving the World from... Diarrhoea Diarrhoea is the second biggest global killer amongst children under 5 (after pneumonia), causing the deaths of 1.5 million children annually. However, it remains relatively neglected as global attention and funding has been focussed upon malaria, HIV/AIDS and TB. To address this shortcoming the WHO and UNICEF have recently released a report titled “Diarrhoea: Why Children are Still Dying and What Can be Done About it” The primary focus of the report is on the seven point strategy for overcoming the global burden of diarrhoea. Two of the points are focussed on treatment: 1. Fluid replacement (Oral Rehydration Salts) to prevent dehydration 2. Zinc treatment to reduce severity of diarrhoea The other 5 points are focussed upon prevention: 1. Rotavirus and Measles vaccinations – rotavirus causes 40% of severe diarrhoea cases. 2. Promotion of early and exclusive breastfeeding and vitamin A supplementation 3. Promotion of hand washing with soap 4. Improved water supply quantity and quality 5. Community-wide sanitation promotion The important point is that many aspects of this strategy can be addressed by primary healthcare initiatives within the community setting. Community-based interventions are especially vital for promotion of early breastfeeding and hand washing. The strategy also highlights the relevance of non-medical interventions in overcoming diarrhoea, such as improved sanitation. For the large part the seven point strategy is not introducing any radical new ideas in combating diarrhoea. There is no
http://upload.wikimedia.org/wikipedia/commons/5/58/Washroom_pictogram_sign_with_braille.jpg magic bullet for diarrhoea prevention and treatment. Instead simple things, such as providing fluid replacement and encouraging breastfeeding, can go a long way to saving many lives. This simplicity is partly what has hindered efforts to overcome diarrhoea in recent years; many global health organisations these days are looking for revolutionary treatments and golden bullets. Perhaps the most significant learning point from this new WHO/UNICEF report is that doing the simple things well is often the most effective strategy for addressing many diseases globally. With any luck this point will be taken on board by global policy makers, and funding for diarrhoea prevention and treatment will increase sooner rather than later. Vishaal Virani Fourth Year Medical Student
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Polio: A Pilgrimage Every pilgrim entering Saudi Arabia for the Hajj this autumn will be required to receive a mandatory dose of the oral polio vaccination. Saudi Arabia has resolved to ensure health officials rigorously oversee the vaccination process in Mecca in a bid to finally eradicate the disease. “50 years after Dr. Albert Sabin invented the oral polio vaccine, polio has been eliminated from more than 125 countries,” said Ted Turner, United Nations Foundation Founder and Chairman, “The Kingdom of Saudi Arabia will help us finish the job. Let’s rid the world of polio once and for all.”1 Polio is a highly infectious incurable viral disease that predominantly affects children under five. The virus enters the body orally before multiplying in the gut and taking over the nervous system. In the most serious 5% of cases, the virus can cause permanent physical paralysis within hours, and of these cases, between 5-10% die when their breathing muscles completely cease to function.2 Before the disease was specifically targeted, 1000 children became paralysed due to polio every day, so in 1988, The Global Polio Eradication Initiative was founded by the World Health Assembly.3 Prior to this there were 350,000 reported cases worldwide, a figure which fell to 1997 cases in 2006.2 This staggering difference, a drop exceeding 99% is attributable to the immunisation of over two billion children, through a global effort requiring the collaboration of a 20 million-strong volunteer workforce of people from over 200 different countries.1 The vaccine costs just $0.60 per jab and has meant that polio is now endemic in only four countries: Afghanistan, Pakistan, and
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http://www.paho.org/Images/DPI/100/vaccine02_large.jpg regions of Nigeria and India.1 Rumours regarding the safety of the vaccine have prevented its widespread use in these areas. By targeting pilgrims in a safe environment en masse, it is hoped that the Mecca scheme will raise awareness of the importance of polio immunizations amongst Muslim pilgrims, many of which are from polio-endemic regions, and that the vaccination team will help clear the rumours concerning its safety.4 Camille Wratten Second Year Medical Student
Global Health Decisions, decisions...
lobal health is a broad issue that attracts interest from politicians, economists, doctors, farmers, mathematicians, sociologists, engineers, teachers, activists and members of the general public; after all, that’s who it affects. It also divides opinion; can we stand by and let populations die? Do we have a right to step in and change ageold traditions and beliefs? Do we have a duty to protect innocent lives? Answering these questions is far beyond the scope of this article, this magazine, this university, even. However, as intelligent members of an increasingly globalised world, these issues will not remain in other continents – they are questions many of us will have to face through the media, disease pandemics or our travels. Whilst most doctors treat the patients in their GP surgery waiting room and politicians often study the health of the population of British citizens, understanding global health means looking at the physical wellbeing of the population of the entire world. Working in the field usually means trying to improve that wellbeing. When the words ‘global health’ are mentioned, many people think of adventurous doctors in Khaki shorts immunising children in South America, charitable NGOs (Non-Governmental Organisations) handing out food parcels during Ethiopian famines or epidemiologists discussing the latest mutant strain of ’flu. These may be accurate, but the long term goal of most global health initiatives is strengthening health systems¹ around the world, which hands responsibility back to local or national governments and empowers them to act independently to maintain the welfare of their people. The World Health Organisation (WHO, the health division of the United Nations) sums up the challenges of global health as providing “equitable [fair] access to essential care and collective defence against transnational threats”² and Dr. Margaret Chan, the DirectorGeneral of the WHO, identifies women and Africans³ as those most in need of global health strategies. So why are these populations so impoverished in terms of health? On a basic
http://burningbosom.files.wordpress.com/2008/03/globe.jpg level, it is because such people have little access to healthcare, be that health promotion (aimed at preventing illness), primary (community medicine), secondary (acute care, often in hospitals) or indeed tertiary (centres of excellence), but this raises as many questions as it answers; why do these people have limited access to healthcare? A lot of it is to do with their financial poverty. In developing countries, with little funding from central government, gross national product can be as low as £534 and corrupt regimes often allocate resources against the wishes and needs of their people. Thus healthcare is often privately run which can lead to poor quality and expensive services5; free healthcare is something we take for granted in Britain. This lack of infrastructure, combined with the low social status of women globally, often results in women being denied education. Basic issues of hygiene and sanitation, the importance of diet and sound medical practices are not taught so generations inherit an ignorance of how to maintain their health. Simple schemes providing clean water and improving crop productivity (which could have greatly improve the health of whole populations) are frequently neglected by local governments and oversees investors. A combination of traditions, poor education and lack of trust (often eroded by previous experiences of private companies masquerading as charities to exploit indigenous populations), native doctors can be trusted more than UN initiatives. Without the necessary family planning programs,
poor communities continue to expand in an attempt to grow out of poverty – inadvertently stretching resources even thinner. Although the global consensus has switched from the provision of immediate relief to more long term strategies of strengthening Health Systems, this does not provide a direct plan for the future. Various countries have different ideas about what constitutes a strong health system; Cuba invests heavily in health promotion, and has achieved the one of the highest average life expectancies in its region (76 years6). Countries like Ghana have been “unbelievably effective”7 in tackling HIV with the help of the [US] Presidents Emergency Plan For AIDS (PEPFAR) and other international funding. Improving the health of these priority groups will involve an international economic effort to relieve poverty, largescale investment into global education programs to change entrenched prejudices, world-wide condemnation of corrupt regimes, and continuing support to health systems on the ground. With global health often missing from the agenda of international summits and so much discussion about global health priorities, it will be up to us, the decision-makers of the future, to choose how best to solve these problems and to ensure “equitable access to essential care” for the worlds most disaadvantaged people. Isaac Ghinai Second Year Medical Student
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Born in the USA Infant mortality rate in the USA is the second worst in the developed world
s debate continues in the United States of America over healthcare reforms, tit for tat exchanges regarding the pros and cons of a socialised health care system have been sprawled across the media. The topic of infant mortality is close to the hearts of many, and has been used as an example by both sides of the debate to explain faults in the respective opposing arguments. Infant mortality rate in the USA is the second worst in the developed world according to a study by Save the Children foundation. For African Americans in the United States, the mortality rate is nearly double that of the country as a whole (9.3 deaths per 1,000 births)1. Infant deaths in developed countries occur mainly from pre-term and low-birth
weight babies. However, a third of these babies in the United States are born to African Americans, who make up only 17% of the total population2. The statistic above has previously been blamed on poverty and poor insurance cover which is rife in African American groups and possibly as a result of racism. However, this argument simply does not deal with the specific issue that there are more pre-term and low weight babies born in the African- American community of the country regardless of class, who are more are at risk of dying before their first birthday than their racial counterparts. Healthcare which was free at the point of delivery, it seems, would not necessarily improve the infant mortality rate of America or, indeed, African Americans. The current argument now proposed is that of social class and possible genetics rather than inherent racism. Risk factors for low weight babies include teenage mothers and obesity3; and these suggest that the social class of the mother could
be a better indicative of infant mortality than race itself. It is also of note that these lower classes are those most likely to be uninsured. It has also been suggested that the “stress” of being an African American4 (linking again to racism which bubbles under the surface of suburbia in America) may be enough to lead to a low-birth weight baby. Tackling these underlying causes would be of much greater use. Sex education, which in certain areas of America is limited to the teaching of celibacy, needs to be reviewed. Ideally health workers should identify and work with mothers at risk of underweight babies so that every care can be taken to prevent tragedy as well as (yet another) public health drive on the dangers of smoking and obesity could. These measures, if introduced, could see America’s ranking improve as well as save many the grief of losing a child. Lauren Hookham Second Year Medical Student
Health Reform: Change we can believe in
s many of you are well aware, the US president Barack Obama is trying to push through a revolutionary health care bill that will provide affordable healthcare for all Americans. This idea has unfortunately not had the welcomed reception from the general public of America. Since inception the bill has proved controversial with many Americans viewing it as socialist. This has lead to the plans being compared to Britain’s very own NHS, resulting in criticism of our healthcare system.
by 8.6million under the previous Bush Administration)1. This means 47 million Americans have not got access to basic healthcare, which is often taken for advantage in the UK. Obama wants to bring down the cost for healthcare so that the 47million Americans are able to access healthcare when they need to. He plans to do this by lowering cost of health care by $2,500 for each family and bringing down the cost of prescription drugs1. This would benefit both the uninsured and insured.
Governor Sarah Palin has even described the NHS as ‘evil and Orwellian’. Many protests have occurred across America where people have voiced their opposition to Obama’s healthcare plan and their dislike for the NHS. However in all this mass media hyped hysteria what is Obama’s healthcare bill actually trying to do?
This plan sounds like the American people are getting a pretty good deal which should benefit everyone. So why are many Americans against it?
At the moment the United States leads the world in health care expenditures, however it ranks 28th1 in the world in terms of life expectancy and thirty-eight countries have lower infant mortality rates. The reason for this disparity is simple. To reap the rewards of Americas health care system you need health insurance, which does not come cheap. The number of Americans who are uninsured totals 47 million (this jumped
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Countless Americans are under the assumption that Obama’s healthcare reform has a socialist agenda. Many are not too keen on the idea of paying for the health provision of the uninsured especially in the current economic climate. In addition many Republicans and groups linked to lobbyists for the healthcare and pharmaceutical industry are smearing the plan and branding it as un-American leading to many misconceptions and the development of fear amongst many Americans regarding the bill.
magcrit.files.wordpress.com/2008/11/ obama2008.jpg congress, however I wish him luck. This bill is a step in a positive direction for America, despite their technological and economical might America is still years behind in terms of its health provision. If this bill manages to get passed it may alter the perception that the American government not only cares for the wealthy but also looks out for the poor. Martin Edobor IBSc Internation Health Student
It seems like Obama will have an uphill struggle trying to get this bill passed in
Ethnicity and Surgery
he mouth forms an integral part of the face. We obviously communicate with it, but there are many things that go wrong with the mouth too. Edward Angler (born 1855) classed several of these wrongs, according to the position of teeth. With class I malocclusions, the first molars meet as normal (but there are other problems with teeth). Class II malocclusions, called an overbite, occur when molars of the top jaw lie in front of molars of the bottom jaw in a closed mouth. An underbite (a class III malocclusion) is the opposite of an overbite, with the lower teeth (and jaw) being placed ahead of the upper teeth when the mouth shuts. Not a smiling matter The problems with having an underbite are not limited to pulling off a winning smile. A frequent issue involves chewing food, as molars might not meet effectively, or barely meet at all, and chewing also makes underbites more noticeable. With fewer teeth meeting, those that enable a person to chew are then at greater risk of wearing down compared to a malocclusion-free jaw. An underbite can also lead to an inflamed temporomandibular joint, causing pain when the mandible is moved. Having an underbite is also associated with speech problems in a significant number
of cases; in a study by Guay, Maxwell & Beecher (1978), people with underbites were found to have their tongues lower in their jaw at rest, and had to move their tongues further back in order to pronounce the /s/ syllable, and this pronunciation was hampered in all but one of the twelve participants1. Pushing of the tongue on to the mandible can cause the lower jaw to grow too much. The process can be worsened by nasal breathing issues, for example enlarged adenoids (tissue located towards the back of the nose), causing the child to breathe through the mouth, and the tongue to exert pressure on the lower teeth/jaw. Breathing problems can have a genetic and environmental origin, and the cause of underbites has been seen in this way too, with experts leaning towards a predominantly genetic origin. A study found that patients with class III malocclusions were likely to share the feature with family members; 84.3% heritability was found between firstdegree relatives2. Ethnicity The prevalence of underbites has been shown to differ between Caucasians and African-Americans. Emrich, Brodie & Blayney’s study involved 6-8 and 12-14
year-old children having a variety of jaw types. The proportion of people with overbites and underbites increased between the 6-8 and 12-14 age groups in both ethnic groups, but the percentages of African-Americans with underbites was greater than those found with Caucasians3. Interestingly, Caucasians were more likely than African-Americans to have overbites3. Class III malocclusions have been found to be more common in Mexican-Americans than AfricanAmericans and Caucasian-Americans4. However, underbites are more prevalent within Asian communities. Researchers, such as Ishii, Deguchi & Hunt, have compared the craniofacial features between ethnic groups, and their findings suggest that certain features do indeed aid the development of an underbite. Their sample was formed of women with class III malocclusions caused by skeletal structure (rather than the angle at which their teeth grew). When comparing the Japanese women sampled with the Caucasian women, the Japanese women were generally found to have a ‘high-angle facial pattern’ greater than the Caucasians5. This basically means that their jaw (at rest) resembles an open mouth more than a Caucasian’s jaw. Another difference lay within the area around the nose - which was found to be proportionally smaller in the Japanese sample5. Ishii et al sug-
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www.uclmedsin.org gest that the ‘high-angle facial pattern’ would lead to underbites being harder to correct within the Japanese participants; their underbites are more severe. Severe cases cannot normally be fixed by braces alone, requiring relatively major surgery. A study showed pictures of Chinese faces (including examples of normal bites, overbites, and underbites) to medical professionals and laypersons in an Asian community. Faces featuring underbites were judged to have the least attractive mouths6. The unattractiveness of underbites has been shown in a study conducted in Britain7. It cannot be said that underbites are universally unattractive, but a simple glance at the standards of attractiveness in models and celebrities around the world speaks volumes. One cannot immediately blame the Western influence on what is deemed attractive in affected cultures; more studies would really need to be undertaken. Yet there is a general consensus that overbites (which are more common in Caucasian communities than class III malocclusions) are more favourable than underbites. On the bright side, a prominent lower jaw is common among superheroes. Surgery This is performed once someone has stopped growing, and patients have to be wary of their mandible continuing to grow later than average. Underbites are
expensive to correct, costing up to and in excess of £6,300 including surgery, but it can be done on the NHS if the underbite does indeed require surgery. To correct an underbite, either the bottom jaw can be operated on, or the top, or both the bottom and top jaws - especially in serious cases. To shorten the lower jaw, the mandible is broken, with teeth and bone being removed as necessary, and then set so that it becomes shorter. There is a fair amount of swelling after the operation, necessitating doses of pain killers. The operation can typically last a few hours; the recovery time for true ‘normality’ can take several months or years. Some patients have had their jaws wired shut for a few weeks, or elastic bands put in to make sure that their molars meet properly when they chew food. There are rare instances where the surgery has gone wrong in some way. Risks revolve around the nerves in the jaw region. An expected side-effect of the surgery is temporary loss of feeling in lower lip and chin, but there is a risk of a permanent numbness - the severity of which will vary from case to case. It boils down to weighing up the risks with the potential benefits. In some cases the underbite will cause considerable physical difficulties, for example in chewing, but in some cases fixing the occlusion is more for cosmetic purposes. The psychological component of banishing an underbite must be taken into consideration. Nicodemo, Pereira & Ferreira (2008) measured self-esteem and
symptoms of depression in patients pre and post underbite surgery. A significant shift was only found in the women sampled; their self-esteem improved, while levels on a continuum of depression fell . No noteworthy change, however, was found in the male part of their sample. This does not necessarily mean that underbite surgery is of less value to the males, considering the improvement in functionality that can follow the surgery. Perhaps the results suggest that society puts more emphasis on the appearance of women than men - allegedly a common belief! In the majority of cases, an underbite will not be completely detrimental to someone’s life, but an annoyance that might lead to bigger problems later in life. Underbite surgery is best performed after growth of the mandible stops, but it can be treated in childhood with braces, elastic bands and other devices. Those with severe cases who are between childhood and adulthood are left waiting for treatment, with no permanent fix currently available to them. The costs within countries without a National Health Service can be prohibitive. Preaching for tolerance and understanding (as if this is a world-shattering issue) seems over-the-top, but no one should have to ask for that in the first place. By Zarus Cenac Second Year Psychology Student
Interested in Access to Medicines in Developing Countries? About 10 million people in developing countries die each year because they don’t have access to existing essential medicines and vaccines. Universities Allied for Essential Medicines (UAEM) aims to make medicines and medical technologies developed at UCL available in developing countries. We aim to do this through a licensing agreement that allows for generic production in developing countries. Wouldn’t you want the research done at your university by students to reach those who are currently too poor to afford it?
Then come along to the next UAEM meeting email email@example.com to find out more. November Issue 4
Swine Flu The Global Pandemic
he outbreak of the H1N1 swine flu pandemic has been one of the defining news stories of 2009. Public fears have mounted in response to its rapid spread. The developing world, which is least equipped to manage the outbreak, is set to be the most severely affected. Swine flu – A timeline In March of this year, a new strain of virus was identified in Mexico as having caused an illness resembling flu. Confusion followed as the virus spread amongst the inhabitants of the small Mexican town of La Gloria. At this stage the international community was unaware that this mystery illness was to become a pandemic which within a short space of time would have infected most regions of the globe. In fact it would be more than a month until the infections were even mentioned in the World Health Organisation’s (W.H.O.) Disease Outbreak Notice. Over the next few weeks swine flu cases were confirmed in the United States, Canada, Spain and New Zealand. By this stage it had become clear to health planners, public health experts and the W.H.O. that the virus was beyond containment. Work ensued on devising strategies to alleviate the effects of the epidemic on a global, local and personal scale. Surprisingly, despite raising the alert level to grade four (meaning that human to human transmission within communities was occuring), the W.H.O. still did not recommend that affected countries close their borders1. Instead, it merely advised those who were ill to avoid international travel. The first two cases of swine flu in the United Kingdom were confirmed in Scotland in late April 2009. The continued spread of the virus led to the June 11th W.H.O. declaration that the outbreak had reached pandemic level six. This meant that the virus was now spreading in an uncontrolled manner in two regions of the world. On June 14th , swine flu claimed its first life in the UK. Over the summer months the pandemic worsened, spreading across most regions of the globe. After the alert level was raised to grade six, the W.H.O. stopped taking accurate recordings of the number of confirmed cases and moved its focus and resources into alleviating the worldwide impact of the disease. The outbreak escalated rapidly; on June 12th, 74 countries had reported a total of 29,669 confirmed cases of H1N1 swine flu and 145 deaths; by 27th September, more than 340,000 cases and 4100 deaths had been confirmed2. What is swine flu? A common misconception is that swine flu is qualitatively different from normal flu. Both are in fact caused by the same infectious agent – the Influenza A virus. Influenza usually enters the body through the airways, from which the infection takes hold and causes sickness. Our immune systems, more specifically our white blood cells, can prevent the infection getting
out of control by recognising and destroying the virus soon after it enters the body. Influenza, like other viruses, can change the way that it ‘appears’ to our immune systems, preventing it from being recognised and attacked. Swine flu is a mixture of four different influenza viruses (two human, one bird and one pig), which cause flu-like symptoms in the different organisms. This particular combination led to a virus, dubbed ‘swine’ influenza but known scientifically as the H1N1 strain, that is particularly effective at evading our immune systems. Swine flu typically presents itself like the more common seasonal flu, with symptoms including a high temperature, a runny nose and muscle weakness. Current recommendations are to seek medical advice over the telephone, rather than attend a healthcare centre where contact with healthcare professionals and other patients could propagate the spread of the virus. For the majority of those infected by swine flu, it is not a serious, life-threatening illness. Disproportionately affected are the young, old, and individuals with underlying medical conditions such as diabetes. Combating the pandemic: global inequalities Tamiflu has been the main treatment used globally to combat the virus. For those most at risk of complications from H1N1 infection, this drug will reduce the severity and duration of infection. Marketed by the Swiss pharmaceutical company Roche, Tamiflu sales have grown significantly as developed countries have stockpiled the drug. W.H.O. anticipates that the swine flu pandemic may exact a greater cost on human life. The winter flu season combined with the ongoing swine flu pandemic could place a major strain on health systems globally. The developing world may suffer acutely, due to limited the health infrastructure and high prevalence of chronic disease (around 85% of the worlds chronic disease burden is sustained by lower income countries3). Countries with a high prevalence of HIV / AIDS, which devastates the immune system, are particularly vulnerable. Another problem for the developing world is their limited access to drugs such as Tamiflu and potential vaccines. Wealthy nations can easily afford to stockpile pharmaceuticals. Poorer countries, in contrast, cannot afford to resource an effective response. This is being partially alleviated by donations to developing countries of Tamiflu and other drugs. Conclusion Uncertainty exists about the future of the pandemic. The world’s most vulnerable people – the young, old, poor and frail – look set to be worst affected. Hopefully, with sustained public awareness and political will, adequate resources will be available globally to limit the human cost of the pandemic. Martin Everson Second Year Medical Student
Further resources: www.who.int/en/
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Re-scribing: ‘Inter Care – Medical Aid for Africa’ is charity which focuses on delivering unused medicines from the UK to multiple health centres in sub-Saharan Africa
ecycling is in. Big time. It started off small but it’s been growing and growing till now pretty much everyone wants in on the act. This rush in popularity has lead to improved recycling techniques meaning that it’s now possible to recycle almost anything – paper, tin cans, plastic, car tyres, mobile phones, batteries, water, food, clothes etc. Something that is generally harder to recycle is medicine. Many patients in the UK do not take the drugs prescribed to them for various reasons. Some patients have multiple medications on repeat prescription and continue ordering and collecting all of them, even the ones they no longer use. In other cases drugs are only prescribed in case certain symptoms occur such as an asthma attack or pain after an operation and so may never be required. When patients pass away, especially older patients who tend to take daily medications, they often leave a surplus of drugs behind them which tend to be binned by the family. In one BBC news video (see: http://news.bbc.co.uk/1/ hi/scotland/7674308.stm) a pharmacist displays over £1000 worth of drugs which were returned by the family of one patient who came into hospital. The Department of Health estimates that as much as £800 million worth of medicine prescribed in primary care is wasted every year. If hospital and other secondary care prescriptions were also taken into account this figure would be significantly higher still. Currently the UK government has no recycling scheme for unused drugs and the majority of unwanted medication is thrown away by patients or taken to the pharmacy for incineration. There is another option
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Recycling unused medicine
http://largestpharmaceuticalcompanies.com/images/pills.jpg however. Inter Care – Medical Aid for Africa is a UK registered charity which collects unused medications from GP’s surgeries in the UK and then delivers them free of charge to over 100 health centres in 7 countries in sub-Saharan Africa. Patients deliver their unwanted drugs to registered GP surgeries and these are then collected by Inter Care and quality control checked by a panel of volunteer doctors, nurses and pharmacists. Certain medications cannot be recycled by Inter Care and these are disposed of as clinical waste. Drugs which can be used are checked to ensure that they are at least 15 months from expiry and are housed in their original packaging with no visible signs of tampering. Suitable drugs are then packaged and sent at regular intervals to the African health centres which have requested them. Inter Care was founded in 1974 by a couple called Dr David Rosenburg and Dr Patricia O’Keefe. Working as GPs in Leicestershire they saw first-hand the wasting of medication occurring in the UK whilst at the same time learning from friends about severe shortages of drugs in Africa. This injustice galvanised them into action and they started collecting unused medications. During visits to Africa in the early 70s Dr David discovered a network of African Catholic nuns who were trained as nurses and who ran small rural medical units. The doctors used this network to distribute the medications they had collected and so Inter Care was created. Nowadays Inter Care supplies over 100 units run by people of many different faiths, including Catholicism, Anglicanism and Islam. Sadly the couple have now passed away but their work is continued by trustees
and other volunteers. How can I help? If this has sparked your interest, there are several ways to help Inter Care continue its work. Firstly, check with your GP surgery to see if they are registered with Inter Care and if they are not, encourage them to look at the Inter Care website and do so. Secondly, if you do know of anyone with suitable unused medication ask them to take it to a registered surgery for recycling. Packaging and delivering the medications to the health centres is the major expense for Inter Care and is increasing significantly over time. To cover this and other costs, Inter Care runs several donation schemes which can be found on their website. Obviously it would be preferably to have less wasted medication in the UK and for the African health centres to be able to afford their own medications without relying on our excess. Greater education for health care professionals and patients and regular medication reviews are needed to help combat overprescription and drug wastage in the UK. Change and development of the pharmaceutical industry along with a host of other things is required to help combat drug shortages and imbalances throughout the world. However whilst we work to achieve these goals, this small but active charity is providing a very practical approach to a significant problem. For more information check out: www.intercare.org.uk www.aidforaids.org Jessica Wynter Bee Fourth Year Medical Student
Rape in Darfur
The human tragedy and targeted military strategy
n March this year, the International Criminal Court issued an arrest warrant for Omar al-Bashir, the Sudanese President, for war crimes and crimes against humanity. He has been indicted for ordering attacks to murder, terrorise and forcibly transfer civilian populations in Darfur. Rape is one of the crimes of which he is accused of directing. AlBashir is the first sitting Head of State to face such charges1. Behind this unprecedented move lies a tragic conflict in Darfur and a re-conceptualisation of rape in conflict. Darfur: the neglected province Darfur is the western-most province of Sudan, bordering Libya, Chad and the Central African Republic. It is a warravaged region, in a nation that has for decades known little peace2. Darfur is an ethnic mosaic, with a shifting myriad of identities based on language, livelihood and appearance3. Mostly an arid plateau, its economy relies on low level agriculture and livestock rearing. Darfurâ€™s infrastructure has been neglected by successive Sudanese governments. The little infrastructure that existed has been destroyed by recent fighting4. The current conflict ignited in 2003, following rebel attacks against military
targets in the regional capital, El Fasher. Opposition groups were protesting about neglect of the ethnic African population by a predominantly Arab government5. The government responded by attacking armed opposition groups, namely the Sudanese Liberation Movement / Army (SLM/A) and the Justice and Equality Movement (JEM), along with civilian populations supposedly aligned with the rebels, particularly the Fur, Masalit and Zaghawa tribes. The violence was orchestrated by the Sudanese Armed Forces (SAF) and affiliated Janjaweed militia6. Mass destruction of villages and displacement Thousands of settlements were attacked by the SAF and Janjaweed in a â€˜scorched earth campaignâ€™. Strikes were characterised by aerial bombing and dawn raids on villages, with murder, torture, burning of property and pillaging3. Aerial photographs demonstrated extensive destruction and abandonment of villages7. An estimated 400,000 are dead and a further 3.0 million displaced8. The majority have fled to refugee camps located around large Darfuri settlements and the Chad border3. The camps lack essential facilities and their inhabitants continue to be terrorised8. While
coordinated fighting has diminished, an increasingly splintered array of militia continues to orchestrate attacks9. Rape has been a dominant feature of the conflict. Sexual violence is underreported due to stigma10. However, the United Nations and non-government organisations (NGOs) describe a horrifically high incidence8. Witness testimonies portray a consistent pattern. The assailants were identified as wearing military uniforms. Rapes were racially targeted, as demonstrated both by the configuration of attacks and the insults used6. The victims were both women and children. Gang rape and sexual slavery were common. Often, family and friends were forced to watch7. In the earlier phase of the conflict, rape was part of the tirade of violence on villages. In the later phase, attacks became more opportunistic, preying on women as they left refugee camps to forage8. Rape: an individual and collective tragedy The consequences of rape for individuals are well understood. Serious injuries result from the associated violence. The most brutal cases cause a vaginal fistula and incontinence10. Victims are at particular risk of sexually transmitted
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CPR), the Convention on the Elimination of All Forms of Racial Discrimination (ICERD), the Convention on the Right of the Child (CRC) 19 and the African Charter on Human and Peoples Rights (African Charter)7. These treaties guarantee the right to life and prohibit unlawful killings, torture and ill-treatment, even in a state of emergency. The African Charter has specific provisions protecting the health and human rights of women and girls. Furthermore, Sudan is obligated, in accordance with Common Article 3 of the Geneva Convention, to protect civilians in war8. Rape as a weapon of war
http://www.usaid.gov/locations/sub-saharan_africa/sudan/images/displaced_persons/photo01_highres.jpg infections (STIs), including HIV / AIDS, because abrasions facilitate viral entry. STIs are prevalent in conflict, spread by sexual violence and population displacement11. Complications include pelvic inflammatory disease, infertility and death10. Rape may result in unwanted pregnancy; Darfuri women cannot access safe abortion facilities13. The psychological consequences of rape are no less severe, and may include depression, post-traumatic stress disorder, and suicidal intention12. In Darfur, many rape victims are children and female genital mutilation is the norm – both increase the risk of morbidity13. Rape is now acknowledged to be an assault to the integrity of communities. Women suffer anxiety born of the threat of attack. Men suffer the humiliation of being unable to protect women and children8. The social consequences are particularly profound in Darfur, which is patriarchal and predominantly Islamic12. Rather than killed, women are left ‘polluted’, unsuitable for marriage or rejected by their husbands. This ‘tainting’ of identity is reported to have reduced bride price. Average age of marriage has also fallen, with weddings hastened to avoid girls being devalued by rape13. Victims are ostracised by their family and community, which in Darfur leaves them physically and economically vulnerable8. Children born of rape are at risk of neglect at birth or stigma later in life13. Effective intervention is required to treat victims and re-build communities. Rape is a medical emergency, necessitating time-limited treatment. For example, contraception is required within 120 hours and HIV / AIDS prophylaxis within 72 hours. Psycho-social care is
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essential to limit the trauma to individuals and communities10. In Darfur, the majority of victims receive nothing, due to the scarcity of facilities and fear of disclosure15. Sudanese government: failure to protect The Sudanese legal system has not provided justice. Rape victims seeking healthcare are obliged to inform the police. However, the authorities have been complicit in allowing the attacks, and harassment is common7. Rape is defined in association with the Shari’a crime of adultery. This allows higher standards of evidence to be required. A woman unable to prove lack of consent may be charged with adultery. Members of the authorities, including the SAF and Janjaweed (which is integrated into the Popular Defence Forces), are granted immunity from prosecution8. The Sudanese government has obstructed the work of NGOs providing aid to victims. Healthcare workers have been arrested for allegedly failing to comply with disclosure procedures and making false claims about the incidence of rape13. In 2005, when Médecins Sans Frontières spoke out against rape in Darfur, two of its staff were ceased16. In 2006, Sudan enacted into law the Organisation of Humanitarian and Voluntary Work Act which imposes severe restrictions on NGOs17. This year, al-Bashir responded to his arrest warrant by expelling 13 NGOs for allegedly conspiring with the International Criminal Court18. The Sudanese government is in violation of international human rights treaties. Sudan is party to the International Covenant on Civil and Political Rights (IC-
Throughout history, rape has been a feature of conflict. Previously, it was regarded as part of the spoils of war, and a consequence of lawlessness and male isolation. This attitude has changed19. Now, rape is acknowledged to be a deliberate military strategy, aiming to humiliate, dominate, terrorise and forcibly displace populations. Rape may also constitute a form of ethnic cleansing, when used to ‘taint’ lines of descent20. This redefining of rape necessitates an extension of accountability, from the perpetrator to the authorities that orchestrate or allow it. International law now recognises rape as a weapon of war7. The Rome Statute of the International Criminal Court, which underpins international criminal law, states that rape may constitute a war crime when committed as ‘part of a plan or policy or as part of a large-scale commission of such crimes’. Rape may be regarded as a crime against humanity when committed as part of a ‘widespread or systematic attack directed against any civilian population, with knowledge of the attack.’ Rape may also form an element of genocide when ‘committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such’8. In 2008, the United Nations Security Council passed Resolution 1820, which describes rape as a tactic of war21. The principles established in international law have been applied in criminal tribunals for the former Yugoslavia and Rwanda23. The International Criminal Court has concluded that the Sudanese authorities and Janjaweed militia used rape as a war tactic. Consensus opinion is that rape in Darfur constitutes a war crime and a crime against humanity1. However its status as genocide is debated. While the attacks are racially targeted, it is unclear whether the intent is ethnic cleansing or the suppression of civilian populations associated with rebel militias22.
The Sudanese government has not signed the Rome Statute and does not recognise the legitimacy of the International Criminal Court18. Al-Bashir categorically denies the war crimes and crimes against humanity for which he has been charged, including directing mass rape24. Recognition without effective action Rape in Darfur is both an individual tragedy and a war tactic used to destroy communities. While the former was well recognised, the latter has only recently been acknowledged in public opinion and international law. The resulting extension of accountability is reflected by the arrest warrant issued against alBashir. Tragically, this step has been futile, and at the expense of humanitarian aid to Darfur. Al-Bashir is unlikely to face trial in the near future18. The vast majority of those orchestrating and perpetrating rape in Darfur have not been held to account8. The expulsion of NGOs has worsened victims’ suffering22. The decline in coordinated violence offers some hope. However, a fundamental question remains – why, despite the world’s knowledge of mass rape in Darfur, have the victims received so little help? Katherine Pitt Second year Medical Student Further Information MSF Shattered Lives Campaign visit: www.azg.be/shatteredlives/index.html
UCL DARFUR WEEK th
30 November – 6 December
Darfur is in crisis. Over 3 million civilians have been displaced by a 7-year civil war. Yet ‘one of the biggest catastrophes of the 21st century’ still remains relatively unknown.
Why? What is happening? And what can be done?
Affiliated with The Lancet, The Guardian, Penguin Books and MSF, this is shaping up to be one of the largest ever events of its kind in England...
For more information join the ‘UCL Darfur Week’ facebook group.
November: Issue 4 B
‘IF YOU CONTRACT AIDS, YOU WILL DIE’
f you contract AIDS, you will die. This is a statement printed in the textbooks of hundreds of school children in Tanzania, a statement that is incorrect in today’s world of modern medicine and technology. However, this myth is the harsh truth for much of the population of Zanzibar, as I discovered working in a school there this summer. The Zanzibar archipelago is situated off the coast of Tanzania in East Africa, where the main health concern is infection with malaria1. Nevertheless, much of the population is underfed, leading to poorer immune system function and increased risk of infection. With half of the inhabitants classified as below the poverty line2 , access to healthcare is limited, particularly for those living in rural areas. Furthermore, as is indicated, the transmission of HIV is rife, and without effective healthcare and education, this will quickly develop into AIDS. For the children in Zanzibar whom I taught, their lives had already been planned in their minds: the girls would get married early, have many children and become housewives, while the boys would take over their fathers’ businesses. As in many less developed countries, there is a blatant gender inequality, and unfortunately this has a huge impact on the health of the population. Indeed, for every one man carrying the HIV virus, five women are infected3 , and this is mainly owing to the chauvinistic traditions of the country. Polygamy is still seen as normal today, leading to further infection within the family. Moreover, there is a widespread belief that sexual intercourse with a virgin will cure AIDS, which means that young girls are often attacked and later infected with HIV4 . This not only has an effect on their physical health, but also their general emotional and mental well-being.
IMPORTANCE OF EDUCATION Despite the obvious issue of HIV and AIDS in Zanzibar, the basic problem is the fact that it is not perceived to be a health crisis in the country5. Health education is the key to prevention, and although children are taught about contraception in school, cultural beliefs play a larger role in shaping their ideas. An individual who is HIV positive is seen as immoral, shameful and contaminated, rejected by their family and friends: an outcast of the society in which they live. The stigma and prejudice associated with AIDS means that someone who suspects that they have the disease would be afraid to get tested for fear of the consequences. Hence, more and more people are untreated and thus pass the virus onto other individuals, increasing the spread of HIV. According to UNICEF6 , young children and mothers are rarely taken into account when discussing AIDS, with the main focus being on teenagers and young adults. However, a large percentage
of HIV transmission in Zanzibar is from mothers to their children during childbirth and in the period afterwards. The discrimination faced by these children can be detrimental not only for their development, but also for their opportunities in the future. Not only are contraception and anti-retrovirals crucial for minimizing transmission, so too is treatment for pregnant women who are also HIV positive. Furthermore, it is essential to educate the male population of the country, since they generally feel uncomfortable discussing such topics as sex, pregnancy and sexually transmitted disease. LOOKING TO THE FUTURE Although the constant battle against HIV and AIDS appears to be never-ending, a positive stance needs to be taken in order to succeed. If more action is taken to ensure that there is enough support for those suffering from AIDS, and to minimize the spread of HIV, the struggle can be overcome. You may ask how this can be done, with the majority of sufferers being in less developed countries such as Zanzibar. Donating money and volunteering abroad are two options, yet by simply raising awareness of the issue, other individuals can be educated about the problem. Indeed, “ignorance and prejudice are fuelling the spread of a preventable disease… it’s up to you, me and us to stop the spread of HIV and end prejudice”7 .
Alisha Allana Second Year Medical Student
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Dr Chikwe Ihekweazu: Consultant Medical Epidemiologist, talks to Perspectives Editor Adaugo and takes us on a journey from medical student to being the co-founder of the Nigerian Public Health Network and how he still finds time to blog
Nigeria. It was time to do something more than sit together and moan. So together with a good friend Ike Anya, we started the Nigerian Public Health Network. We literally invited Nigerians working Public Health to join us, to firstly support each other in our careers but to also try and influence policy in Nigeria, the best we can. So that started as a kind of informal group but it kind of snowballed as we invited other people. Network started 6 years ago and today we have over 200 members. It then metamorphosed into the Nigerian Partnership for Health Foundation (NPHF). We recently applied for charity status in UK in order to engage in a more strategic way with health in Nigeria while in the UK. A: Can you give an example of what the NPHF can do?
Adaugo Amajuoyi: How did you get involved in Epidemiology and Public Health? Is it something you always wanted to do? Dr Chikwe Ihekweazu: No. During medical school, my big hero was a top successful surgeon in Nigeria, he walked around the hospital with broad shoulders, fully aware of the hoard of registrars running about after him. It was my dream to be like him. When I left Nigeria after medical school at the University of Nigeria, Enugu my plan was to go to the USA via Germany. Because of the time it takes between the USMLE exams, I didn’t want to spend the whole year waiting to take exams, so I registered for a Masters in Public health (MPH), so make maximum use of my time. I was fascinated by what I heard and for the first time since I became a medical student I wasn’t just cramming, I was given complex issues to think about and to find solutions for. It was a totally new life me, something I really enjoyed doing…. thinking, not cramming! Towards the end of my MPH, I applied for a fellowship to attend for the International Conference on HIV/AIDS conference in Durban, South Africa, at the time it was seen as the epicentre
of the AIDS epidemic. At the time antiretrovirals weren’t widely available on the continent and there was a big push advocating for treatment to be made available at more reasonable prices in places they were needed most. I knew then that this was what I wanted to do. But it was still a tough decision. Initially I thought of public health as a hobby and thought I would always go back to clinical medicine. But after this conference I knew that this was where my path lay. A: So your medical career became more directed towards Public Health after Durban. How did you then become more interested specifically in Nigerian Public Health? C: So I got my MPH and got a job in Germany, did that for a few years continued along those lines. In a similar kind of moment, another turning point occurred. A couple of colleagues and I were attending another AIDS conference in Barcelona as then AIDS had become a major part of my work. There were a lot of Nigerians at that conference who travelled from across the globe, and like always, we attract each other end up in a bar in the evening. While in this bar we started talking and realised, that all of us there were passionate about public health and
C: The network was a way of looking for partners to collaborate with on projects in Nigeria. There’s are a lot of resources available for global health at the moment, especially in Nigeria. We feel that we are in a unique position to bid for some of these funds. To implement projects on the continent requires a lot of technical and socio-cultural expertise. We have also found that to get that expertise locally in Nigeria is sometimes challenging so consultants are often outsourced from the West. Members of the NPHF are in a unique position, having both benefitted from the excellent training available in many countries in the West and therefore able to match the expertise offered by colleagues in the West and at the same time have the social/cultural competence to work in Nigeria. We consider this a unique advantage. A: As you mention the idea is similar to redirecting highly skilled medical doctors from the UK to work in Nigeria and get involved in Nigerian healthcare. There is an increasing trend of doctors trained abroad travelling and returning to their native countries to work in both private and public health sectors. If we and other developing countries like Nigeria could do the same there’s a possibility they could benefit from this growing medical tourism. C: I agree, firstly we have to realise that Nigerians abroad are a resource and not their adversary to Nigerians at home. There is a lot opportunity to be created by encouraging Nigeria’s from abroad back home. What happened in India is no coincidence, the country has had a proactive approach encouraging people to come back. This makes
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www.uclmedsin.org the environment suitable something we need to explore and pushing. But we’re not deterred and we have made a lot of progress from a small group. I also think that the current minister of Health Professor Babatunde Osotimehi is quite progressive on what he plans to do for Nigeria. A: That brings me to another Minister of Health. Back in 2007 we both attended a talk with the then Minister of Health Dr Adenike Grange, sponsored by UCL and the Lancet. She discussed the increasing mortality rates of women and children in Nigeria due to poor access to basic primary healthcare. I particularly
“the only way for Nigeria to change will be if people are ready to get their hands dirty” remember your very direct and amusing question that went something along the lines of “what do you plan to do to change these statistics and how can we hold you accountable to show for your work within the next few years of your period in office ?” She never did answer that question as directly as you put it. C: (Laughs) well yes but there is a bigger problem in Nigeria’s health care system – Management. The best clinicians are catapulted into management positions but have no management expertise. And they don’t know what strategic thinking is about or how to manage a budget. Many have never managed a team before beyond their. They suddenly bring a professor of paediatrics (Dr Adenike Grange) who in her entire career knows everything about paediatrics but she’s not a manager and suddenly she’s made minister of health. And this is pervasive across the entire system. It is no surprise then that she delivers a talk where she talks about the problems and not how she plans to solve them. This is what is missing. I think the current minister of health has learnt a lot from the predicament of his predecessor. The management of our health services is a huge problem and while lot of emphasis goes into clinical expertise, and infrastructure but not enough is put into how to manage the resources. For example with the NHS, the idea of amalgamating services to create Polyclinics is an example of making use of limited resources and is clear example of healthcare reform. That’s what we need to focus on in Nigeria; the strategic thinking required to manage the available resources.
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Nigeria, in my opinion compared to other African nations has far better infrastructure and huge expertise but its potential is not being utilised. For example a referral system from primary to secondary to tertiary in Nigeria is nonexistent. People don’t know how to refer, who to go to, etc these are system issues, that can’t be solved by building more hospitals. A: So with the wealth of students here in the UK eager to go back to Nigeria to do something, but don’t know where to start. How would you advise us? C: The truth is, it’s not easy. But having said that there a few pockets of hope emerging in Nigeria and my advice is to find a platform to engage. You are not going to find a perfect set up where you email someone, and everything else is arranged! Still young enthusiastic medical students have to show the way. The only way for Nigeria to change will be if people are ready to get their hands dirty. In an article we published in the Lancet 5 years ago, 50% of my classmates, had left Nigeria. I have to emphasise that it is not the average 50% but the top 50%. So we’re leaving an entire country with the remaining 50%, the less than average medical doctors, you don’t expect professionalism. So that’s why I feel that I don’t have the right to complain, I don’t feel that I’ve done enough. I can only complain when I feel that I’ve done my best and I don’t think enough of us have. We have to earn the right to complain, by trying the best we can to make things better. We just might actually stop complaining when we have tried! A: I have to agree and disagree, you are doing a lot, in addition to being a Public Health Physician, regional Epidemiologist for the South East, running the NFPH, you also write a blog dedicated to Nigerian Healthcare, titled the Nigerian Health Watch: http://www.nigeriahealthwatch.com/ When did you start the blog? C: Three years ago. Ike and I went to the TED (www.ted.com) conference in Tanzania. It is held every year and people are invited to come and talk about their experience and what they have done in order to inspire others. When I was invited I was initially sceptical about leaving very important work to go to what I thought of as a holiday. It turned out to be a truly inspiring event. At the same time we heard from a lady in Kenya who went to the Kenya parliament every day and wrote a blog on proceedings. Making this information available to the public for the first time. The blog became
extremely popular as it was one of the only ways the average Kenya would be able to hear about what was really happening with their Government. Realising the power of blogging, Ike and I decided to start one focusing on Nigerian Health care. We have had good feedback and encouragement from people saying that it is very good, although it is a struggle to keep up. A: You’re too modest; your blog is fantastic, easy to read and is such a great source of information on healthcare in Nigeria, and I found it particularly exciting that the aids to Bill Clinton contacted you for some background information for Clinton’s support team ahead of his trip to Nigeria. Any way before we finish, we must talk about the conference you organised last November, Nigeria: Partnership for Health Conference held at UCL. Lande Ogunsanya and Lois Haruna (both 4th year medical students) and I helped out and attended the conference. We were very impressed by the speakers and the quality of the workshops. C: (Laughs) You can’t believe the amount of pressure it took to organise but yes, we plan to another conference next year. From the energy in the room on the day, you could really feel that people were frustrated by the conditions in Nigeria. But we made a conscious decision not to do another one this year as we want the next conference to focus on what people are actually doing, what projects are available to join. We also hope to make the event a two-day event, with the first day on public health and the second on curative medicine. There is a lot going on in Nigeria but sadly these projects are in spite of government and not because of government, something we hope to change. We also want to try and give opportunity for students to engage. A: Hopefully it would be something UCL Medsin will be able to get involved in. C: Absolutely, we would also like to arrange workshops for student thinking about starting internships, research or gaining work experience abroad. A: On behalf of UCL Medsin and Perspectives, I would like to thank you Dr Chikwe Ihekweazu C: Thank you Please visit his blog on: http://www.nigeriahealthwatchcom/ Nigerian Public Health Foundation Details for the Nigeria: Partnership for Health Conference: http://www.nigeriahealth2008.org/faq.html
Binge Britain The ‘new British disease’ is now reaching epidemic proportions.
ritain is increasingly becoming known for its boozy binge drinking culture, with what Tony Blair once described as the ‘new British disease’ now reaching epidemic proportions. In fact, the U.K. has one of the highest rates of binge drinking in Europe, and an overwhelming amount of research shows that young people are at the root of Britain’s binge drinking blight.1 According to the Institute of Alcohol Studies, youth in the UK are the third worst binge drinkers in the EU2, behind Ireland and Finland3. Scotland’s recent plans to implement a set minimum price for alcohol and change the way alcohol is sold and advertised, has brought this issue to the forefront of public interest once again, and puts increasing pressure on Government to tackle binge drinking. Drinking to get drunk Definitions of binge drinking, also referred to as ‘heavy episodic drinking,’ are varied and often vague, however one government report on binge drinking and public health released in 2005 described binge drinking as ‘the consumption of excessive amounts of alcohol within a limited time period.’4 As a result of such behaviour, the blood alcohol concentration (BAC) is rapidly increased and drunkenness subsequently ensues. But what amount of alcohol is actually classed as ‘excessive’? According to the report, it is double the daily unit guidelines outlined by the Department of Health in 1995, which equates to six to eight alcohol units for men (equivalent to three pints of lager) and four to six units (two large glasses of wine) for women in one sitting.5 However, stronger drinks and larger glass sizes now make it much more difficult for people to keep track of their daily unit tally. Young groups who are pre-drinking at home before a night out are also increasing their risk of surpassing the safe unit guidelines, as they consume unmeasured over generous amounts of alcohol. The unpleasant facts Whilst latest figures show that the pro-
www.caterersearch.com/blogs/catering-news-blog/2008/03/darling-puts-up-beertax-1.html portion of young people drinking alcohol between the ages of 11-15 has decreased in recent years, with a reduction from 62 to 54 per cent, the actual volume of alcohol consumed by the same group of individuals has worryingly increased from 6.4 units per week in 1994 to 12.7 units per week in 20076. The largest increase was seen in 14 year olds, whose reported alcohol consumption rose from 6.1 to 9.9 units on a weekly basis.7 Information gathered from 35 European countries in 2007 by the European School Survey Project on Alcohol and Other Drugs (ESPAD), provides additional evidence of the acute problem facing Britain. Not only did Britain have the third-highest proportion of 15 year olds reporting being drunk 10 times or more within the past year,8 but UK teenagers were the third most likely to have been drunk within 30 days of the survey (behind Denmark and the Isle of Man). The Liberal Democrat health spokesman, Norman Lamb, described these recent findings as ‘bleak’ and commented “Our children drink more, get drunk more often and are less worried about the potential harm alcohol can cause than their counterparts in almost all of Europe.” Internationally, of the 41 countries and regions across Europe and North America included in the 2005/2006 Health Behaviour in School-aged Children (HBSC) Survey, the UK has the highest proportion of girls(24%) that reported being drunk at the age of 13 or younger.9 Dicing with Death
Indisputably, these high levels of alcohol consumption impact negatively on the health and wellbeing of young people, with the consequences of excessive drinking ranging from vomiting, dizziness and headaches, to loss of consciousness, suffocation as a result of choking on your own vomit and potentially lethal alcohol poisoning. Impaired judgement additionally increases a person’s risk of accidents, injuries and unsafe and sexual encounters. However, the end of a hangover does not signal the end of the costs of a heavy drinking session, as regular binge drinking can also dramatically impact upon health later in life. As well as being associated with weight gain, diabetes, stroke and mental illness, alcohol use is connected to cancers of the mouth and throat and also liver disease. In fact10, the number of cases in the UK of chronic liver disease and cirrhosis has increased progressively in the last 30 years, with a significant rise in the 25-34 age group; from 16 male and 7 female cases in 1970 to 68 male and 60 female cases in 200011 - a rise that correlates with increased alcohol consumption.12 Speaking of the recent rise in alcoholrelated deaths, Alison Rogers, the chief executive of the British Liver Trust, said: “The death toll from alcohol remains unacceptably high, and twice as many people are dying from alcohol as 15 years ago.” The serious side to getting smashed In terms of the wider social effects of alcohol misuse, alcohol has long been linked to anti-social, violent and crimi
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www.uclmedsin.org nal behaviour, with research connecting alcohol consumption to 50% of street crimes, 30% of sexual offences and 33% of burglaries13. One survey carried out by the Home Office found that 18% of 12-13 year olds and over a quarter (28%) of 14-15 year olds caused damage whilst drinking, while one in ten 15-16 year olds said that drinking had led them to get in trouble with the police.14 Yet, the police are not the only ones bearing the burden of rising alcohol misuse. Official statistics also illustrate the undue strain binge drinking places on the NHS and emergency services,15 with roughly 70% of cases at A&E departments between midnight and 5am on weekends directly related to alcohol consumption.16
“Our children drink more, get drunk more often and are less worried about the potential harm alcohol can cause than their counterparts in almost all of Europe.” According to a 2003 government report17, £20 billion is spent annually on crime and disorder, health damage and lost working days due to alcohol consumption in England and Wales18. During current difficult financial times, many may question why more is not being done by Government to tackle this anti-social and economically expensive behaviour. Overcoming over-drinking Clearly, the strategies, laws and schemes currently in place to reduce binge drinking are ineffective. Perhaps the most highly criticized government measure has been the relaxation of licensing laws in 2005, which allowed round-the-clock drinking in pubs and bars in the UK for the first time. It was hoped that by staggering closing times it would help to reduce the number of intoxicated people simultaneously pouring out onto the streets, thus making areas easier to police. In fact if anything it has made the situation worse, with UK town centres filled with very drunk and often very aggressive and voilent youths each weekend. Certainly, the biggest issue to overcome is the social acceptability of youth drinking and alcohol’s place in our leisure culture. Whilst many other European countries, including France, actually drink more alcohol than Britons do per year, their drinking habits are much less harmful. In the case of France, individu-
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als typically drink two or three units every day, and avoid British-style heavy drinking sessions at the weekend. Education will of course be vital to changing beliefs and values; however it is difficult to educate people on the risks of something so readily available to the public. Whilst the success of the government’s drink-driving campaign shows that it is possible to have a positive influence on behaviour in Britain; the findings from the 2007 ESPAD study, which reveal British teenagers were the most likely to assert that they expected “positive consequences” from drinking than those from all other European countries, show that action is necessary. Regulating availability The availability of cheap alcohol has also been tied to youth drinking trends, as young people can head to supermarkets and corner shops to buy cheap promotional booze and avoid high alcohol costs in clubs and bars. Promotions, such ‘two for the price of one’ and ‘all you can drink for £10,’ are thought to be adding to the UK’S binge drinking crisis19, which is why the Scottish National Party is taking steps to become the first European country to enforce a minimum price for alcohol, and ban money-saving marketing schemes from stores and licensed premises. Scottish Health Minister Nicola Sturgean said, ‘Plummeting prices and aggressive promotion have lead to a surge in consumption causing and adding to health problems...The time has come for serious action.’ An encouraging report by the Department of Health found that alcohol consumption would fall by 2.6 per cent if a minimum price of 40p per unit was enforced in England. As a result hospitals would see alcohol-related admissions decline by 40, 000 a year.20 However, a number of people share the concerns of David Poley, Chief Executive of the Portman Group responsible for UK drinks producers who said that “These plans will punish all drinkers while only scratching at the surface of our drinking culture.”21 Others opposing the plans argue that taxation should be used to raise prices of alcohol, rather than setting minimum pricing of units which restrict businesses’ ability to fix their own prices. So, is the party over? Similar to the ban on smoking in public places, Scotland’s lead on binge drinking has forced the current Labour Govern-
http://youraustinattorney.files.wordpress.com/2009/02/alcohol.jpg ment to take notice and push for similar restrictions on alcohol pricing and promotion. Yet Gordon Brown’s promise to introduce a new mandatory code on alcohol sales is set to see serious delays following the expression of concern from Business Secretary Lord Mandelson on the undue strain such efforts would place on struggling businesses during the recession. Yet hope comes in the form of a £100 million five-year campaign, launched on the 1st September, which aims to tackle Britain’s drinking culture by advising 18 to 24-year-olds to evaluate their drinking habits.22 According to the alcohol charity Drinkaware, the ‘Why Let Good Times Go Bad?’ Initiative, which is supported by both the Government and the drinks industry, will see warnings placed on 13 million products, including neck labels on bottles, cans and multipacks. Supermarkets, pubs, off-licenses, and phone boxes will also display campaign posters, drink mats, and stickers with advice on responsible drinking. Chris Sorek, chief executive of alcohol charity Drinkaware, said: “Changing the drinking culture in Britain won’t happen overnight but, with the right support, information and advice, young adults can change their own drinking patterns.”23 Until we change the social and cultural context in which alcohol is viewed, and learn from the behaviours of our more sober European neighbours, I fear raising prices will do little to control or eradicate binge drinking in the UK. Harriet-Rose Malone Second year Human Sciences Student
A Decent Proposal Suitable vaccines at affordable prices
he members of the global health partnership of the Global Alliance for Vaccines and Immunisations (GAVI) work together to achieve what no organisation could alone: saving lives by increasing access to vaccines. In February 2007, the Canadian, Italian, Norwegian, Russian and British governments, along with the Bill & Melinda Gates Foundation, committed US$1.5 billion, with GAVI promising a further $1.3 billion, to start the first Advance Market Commitment (AMC). This summer, GAVI CEO Dr. Julian Lob-Levyt announced that funds were finally all in place. GAVI’s innovative approach to public funding in international health aims to stimulate vaccine development and manufacture specifically for developing nations. The first AMC focuses on pneumococcal disease which is the world’s deadliest threat to children under the age of five. Pneumococcal disease wipes out 1.6 million people each year, 1 million of whom will not even reach their fifth birthday and 98% of which occur in developing countries. HIV, TB and malaria combined will kill fewer children under 5 than pneumonia, yet, thanks to the AMC, 7 million lives will be saved by vaccinating 1 billion children by 2030. In essence, this initiative is designed as a financial incentive for vaccine makers. Donors commit money which guarantees the price of vaccines once they are developed, and thus the existence of a feasible future market. This provides vaccine makers with the motivation needed for them to invest into conducting research, training staff and building manufacturing facilities. Jim Connolly, Head of Vaccines at Wyeth, acknowledged that “we have an obligation to make products available to as wide a popula-
http://www.gavialliance.org/media_centre/features/2009_04_23_rwanda_pneumo_ guide_mdg4.php tion as possible”. Financing mechanisms like the AMC make this “affordable from a country’s perspective and sustainable from a shareholder’s” (Connolly). Under the AMC, GAVI will sign 10-year deals paying $7 per dose for the first 20% of vaccinations provided. This will allow companies to reclaim research and development costs. Prices will subsequently drop so that developing nations receive these urgently important vaccines at a favourable $3.50 per dose. In the AMC framework, the World Bank will be responsible for financial support whilst the WHO will set the technical standards and UNICEF will be engaged in vaccine procurement and distribution. The idea is that pharmaceutical companies bid for contracts creating the market competition necessary to obtain the best product for the best price. The additional benefit has been that both multinational companies as well as emerging pharmaceutical companies appear to be competing for contracts. The current available pneumococcal vaccine is not ideal for the majority of the world. This is because it was developed to protect against strains in rich countries, therefore a critical GAVI ob-
jective is the development of a more powerful vaccine to protect against strains threatening poor countries. Wyeth, GSK and the Serum Institute of India are all working towards achieving this goal, and if the WHO’s criteria are satisfied and recipient countries demonstrate the ability to effectively distribute the vaccines, Dr. Orin Levine of the John Hopkins School of Public Health predicts it could be as early as the end of 2009 that we would see the pneumococcal vaccine become part of national immunisation programmes across the developing world. In April 2009, Rwanda became the first developing country to include a pneumococcal vaccine, Prevenar, in its national immunisation programme thanks to a donation by Wyeth, through GAVI. Wyeth’s president, Bernard Poussot, now looks “forward to working with GAVI and other global partners to help make the AMC pilot a reality”. The AMC will ensure that the historic roll-out of pneumococcal vaccines does not finish at Rwanda, and that by 2015, GAVI will have helped 60 countries in the developing world. “The AMC is an important step towards reducing the health inequities between rich and poor, and a way to protect the lives of the world’s poorest children”, (Dr. Lob-Levyt). If the AMC framework proves successful, it will undoubtedly be applied to not only target vaccines for other diseases, such as HIV/AIDS, TB, and malaria, but for their treatments as well. As Dr. Lob-Levyt has recognised, “potentially this could be saving millions of live”. Nidihita Singh IBSc International Health Student
November: Issue 4 B
Recession Depression The psychology of the future of the economy
here is no doubt that the recent economic downturn has brought a lot of stress and psychological consequences to many who face unemployment. According to Air Transport Association, eight airlines have gone out of business since December 2007 due to rising fuel prices. 1Numerous companies have also been laying off staff to keep themselves from bankruptcy. eBay, Sony Ericsson, and Motorola have let go of 1000, 2000 and 3000 workers respectively. Others such as Hutchinson Technology cut more than 44% of its jobs and Microsoft has sent 2 waves of layoff notices so far in 6 months.2 It is known that redundancies can lead to feelings of humiliation, embarrassment, sadness, guilt and frustration. In addition, other powerful emotions may also be involved if the job has been financially supporting more than one person. If these emotions are not dealt with properly stress symptoms such as insomnia, panic attacks, and colds brought on by a weakened immune system may arise. These can later progress to depression. Redundancies would also remove people from the routine and conviviality of working life, bringing about unaccustomed isolation.3 Polls made in 2008 show that 3 out of 5 Americans believe the United States is headed towards a 1930’s style Depression. Surprisingly, economic downturns are also partly psychological. If enough people act and behave like we are heading towards a Depression, we will. This phenomenon is called the self-fulfilling prophecy.4 It is not just the external factors that can cause a Depression but rather the response and behavior that people emit. A ‘depression’ is characterized by a ‘decline in real Gross Domestic Product (GDP) of more than 10%, or a contraction in real GDP which lasts more than three, or four, years’5. The 1930’s Great Depression fulfills both criteria with a 33% decline in real GDP from September 1929 to September 1932 and a 13% decline from September 1937 to March 19386. This is not the case with the current financial crisis which started in late 2007. Although leading economists would agree that the current recession
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http://realestateprogram.blogspot.com/2008/10/empirical-research-on-international.html is the most serious next to the Great Depression7, it has not lasted more than 3 years and the decline in real GDP has not exceeded 10%. GDP reduction has been forecasted as 5.7% in the UK8 and 3.9% in the US for 20099. The US suicide rate during the Great Depression increased from 1929 to 1933 from 13.9 per 100,000 to 17.4 per 100,000.10 Harvey Green claims that domestic violence and child abuse also increased during this time. To counter the negative effects brought about by this phenomenon, people turned to the entertainment industry which boomed to an average of 80 million people visiting the cinema each week.11 Compared with the 1930s depression, people today are better equipped with handling economic crisis12. This brings about better psychological health than that of the 1930s. A study entitled ‘Trading Up, Trading Down’ was conducted by BBDO and Proximity which discussed the change in spending habits of Singaporeans and Filipinos in their respective countries in light of the recession.13 14 This study has been conducted to benefit brands losing consumers so that they will know how to market their product during the economic downturn. As opposed to the 1930’s depression, we are now equipped to fight the recession with the use of research as well as media and communications. The growth of psychological research has definitely contributed to the improvement in psychological health even in times of hardship. The internet is also
a big advantage that many have compared to counterparts in the 1930’s. Try googling the word ‘recession’, ‘layoffs’ and ‘psychology recession’ and you will get a lot of sites offering advice on how to cope with the recession. There are also articles on how to soften the blow of the recession15. The emergence of humanistic psychology in the 1950s16 made popular these self-help resources that are often turned to in times of emotional and mental pain. The onset of social media networks also make the blow of the recession easier to overcome. On facebook, there is a group called ‘This Recession is OVER!’ aiming to get the global economy going again17. These are available for self-expression to release pains and frustrations which is essential for psychological well-being. These online networks also provide virtual companionship to people who feel that they are alone in their struggles. Real advice, stories and solutions which can inspire other people are shared online, making one not lose hope so easily. Finally, awareness of what’s going on makes a big difference in our psychological health as compared to the 1930’s depression. In the past, people were uncertain about what was going to happen so they didn’t know how to act. Today, we have a wealth of information available at the click of a mouse. We are able to find the resources and help we need with the aid of digital media much faster than before. Jamie Tolentino Second Year Psychology Student
Roma Gypsies With an estimated average life expectancy between 32 and 55 years, Joshua Balkin examines the plight of the Roma gypsies
ou may have seen a recent BBC â€˜This Worldâ€™ episode featuring gypsy child thieves, which explored the Roma gypsies and their way of life. It conveyed a mixed message, portraying some gypsies as victims and some as criminals, but whichever conclusion you reach, there is no denying that it revealed startling footage and statistics of how many millions of people are living in destitution across Europe. Some experts have drawn comparisons to the Australian Aborigines, who have been shown to experience a standard of living substantially worse than other Australians, with shorter life-spans and more easily-preventable infectious diseases. A shocking difference, however, is that while the Aborigines make up 2% of Australiaâ€™s population and the Australian government has spent millions of dollars on their health, the Roma make up more than 10% of the population in Eastern Europe, and most governments seem to be apathetic to their plight. The history of Roma gypsies is complicated and unique, and reaches back over 1000 years. Originating in Northern India, tribes gradually migrated Westward across Eurasia, and had settled in the Balkans and parts of Western Europe by the fifteenth Century. Religious and cultural differences triggered the beginnings of hostility and repression towards the Roma, and by the end of the 16th Century discriminatory legislation was in force across most countries. This attitude led to a consistent campaign of oppression against their populations, with aggression taking the form of banishment, forced assimilation and genocide, perhaps most memorably in the Holocaust when up to 500,000 gypsies were exterminated in Nazi camps. It is extremely difficult to even write with confidence about the health condi-
nabeelfarah.tripod.com/.../flowers2.jpg tions of the Roma, due to a dearth of research or available information. This feeds into a vicious cycle, as information is necessary for public health interventions, and the authorities are given another reason to avoid trying to improve the health of Roma populations. A combination of appalling living conditions, poor education, and limited access to healthcare has contributed to Roma gypsies having some of the worst health of any population in the industrialised world. The gypsy camps that are home to most Roma are overcrowded
and without basic sanitation, where rodents run rampant and children play in piles of putrid rubbish. Infant Mortality Rates are unusually high, often four times that of the populations living in nearby towns, and average life expectancy has been estimated at between 32 and 55 years. The intense population density, with up to 12 living in a room, promotes the prevalence of infectious diseases such as Hepatitis viruses, TB, and other respiratory infections. Substance and alcohol abuse, and smoking from an early age, also has an affect
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www.thewip.net/ on Roma health, and a lack of awareness about the health risks involved compounds the problems and ensures that the Roma won’t follow any positive trends seen in the rest of Europe. The vast majority of Roma children don’t complete primary education, and half of their parents have had no schooling whatsoever; this presents obvious problems, chiefly an ignorance of health risks and appropriate lifestyle choices, but it also restricts their access to mainstream healthcare. Ethnographic research among American Roma has identified a belief system ingrained in the society, involving rituals, concepts of purity, and traditional healers- all of which can obstruct the acceptance of Western ideas regarding healthcare and illness. A recent report by Human Rights Watch claimed that several Roma camps in Kosovo are contaminated by lead pollution, due to their proximity to lead mines and slagheaps in an area known for its environmental pollution, the Trepca complex. Children are most vulnerable to lead poisoning, and continuous exposure can result in stunted physical and mental growth, with the worst cases resulting in kidney failure or brain damage, or even fatalities. The families have been beset by air, water, wind, and soil contamination for a decade and the report urges the EU and Kosovo authorities to finally solve the crisis and move the camps away from the dangerous area, and to
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“rodents run rampant and children play in piles of putrid rubbish” provide medical treatment for lead poisoning to all residents of the camps. This case is one of many similar instances where Roma have been exposed to dangerous conditions as a result of their environment. Often forced to build camps on ‘discarded land’ close to motorways or industrial areas, or under power-generating pylons, their health is endangered; and their limited access to healthcare means they have to suffer for it. The Roma gypsies are a long-suffering and much maligned population, and they often suffer multiple hardships through little fault of their own. They are among several neglected communities in our countries and times, but they are arguably the worst affected by detrimental living conditions and racial insensitivity. To live in a democratic society and yet read about the marked inequalities
facing thousands of people on a regular, widespread basis is certainly an uncomfortable contrast, and will hopefully be rectified soon. As public awareness of these problems grows, authorities will be more motivated to create solutions and combat the negative trends that have arisen, and with outreach measures and collaborative campaigns, improve the health of some of Europe’s neglected communities. To improve the health in Roma populations, schemes are reliant on information; therefore, researchers should be pressured into spending some time investigating the current situation in Roma camps, and possible solutions to improve it. Co-operation and understanding are essential for this and other projects, and so relations between the Roma and their neighbours have to be worked on as well. Deep-seated attitudes must be confronted and tackled, on both an individual and a population level, to root out racism and discrimination. As ever, education is a vital first step in population health, and this must be addressed too. But for starters, I believe it is a step forward that you are now even aware of the problem. Joshua Balkin Second Year Human Sciences
Reviews Three Cups of Tea By Greg Mortensen and David Oliver Relin Greg Mortensen’s story is told by award winning journalist David Oliver Relin. The account begins with Mortensen’s failed attempt at climbing K2. Whilst trying to find his way back, he stumbled upon the small village of Korphe. Their kindness inspired him to start building schools in the impoverished mountains of northern Pakistan, drawing his attention away from mountaineering for the first time. His fund raising efforts for his first school were slow and strikingly self-less; he worked as an ER nurse during the day and for a year he spent his nights in his car in order not to spend money for the school on rent. From the moment he meets the Balti people and throughout the book one striking theme is the way in which Greg Mortensen consistently works with the local people and slowly builds a team of people he can trust and work well with – with no entourage of Americans and no imposition of Western ideas. The descriptions of the Himalayas, their immensity and grandeur made me want to grab a pair of hiking boots and book a flight out to Pakistan. Yet it is this very same immensity which creates a physical barrier, cutting the Balti people off and making Mortensen’s work all the more necessary. The book opened my eyes to the world of mountaineering. David Oliver Relin explains the stories of Sir Edmund Hillary and Isabella Bird. The strong mountaineering community is what ultimately allows Greg Mortensen to dedicate all his time to the projects through their support and found CAI – Central Asia Institute. At times, the books reads like a thriller, interspersed with kidnappings and local religious leaders issuing fatwas opposing the building of the schools. Yet the genuine idealism, naivety and nervousness of the ‘hero’ gives it a caring human quality. Even though many schools have been built and Mortensen has witnessed first hand the increase in the amount of Wahhabi madrassa in the area and Taliban, Mortensen feels his schools are an alternative for the students in the Kashmir region to fight ignorance and the extremism which can breed.
The reader gains an insight into a part of Pakistan from the 1990s until today and how it has changed; the politics and the effects of 9/11, the Afghan refugee situation and the media coverage of it all. All these difficult subjects are presented in a very accessible way and in a way that is sensitive to the local population’s reactions – something we rarely see in the media coverage of the situation today. Through the small anecdotes and stories, many of which are humorous, you begin to understand how this man, Greg Mortensen, has managed to succeed in this rather impossible sounding feat:
Through many small steps, dedication, self-sacrifice, humility, patience and above all – cups of tea. By Elena Ferran Fourth Year Medical Student
Three Cups of Tea Published by Penguin, 3 Jan 2008 The Bottom Billion Published by OUP Oxford, 2 Oct 2008
November: Issue 4 B
The Bottom Billion: Why the Poorest Countries Are Failing and What Can Be Done About It. By Paul Collier In 1980 we saw the beginning of Children In Need, this was closely followed by Comic Relief in 1985. On July 13th of that year Sir. Bob Geldof held ‘Live Aid’, which was to be repeated 20 years later in 2005 as it was resurrected as ‘Live 8’. Together all the charities and events ever held to raise money in order to abolish poverty have successfully donated billions of pounds to the world’s poorest countries. It makes us feel pretty good, donating all that money through sponsored swims, endless school uniform days and three legged races, we thought we were changing the world. Until ‘The Bottom Billion’ came to realisation. Paul Collier is not a politician, nor is he a journalist or even a medical professional. Paul Collier is an economist, and a very good one at that. He has spent years looking into the economic history of the worlds poorest nations, trying to find out why so many of them are, for want of a more polite word, failing. His findings, conclusions and suggestions for rectification may come as a surprise to some readers, for example Collier recognises that Britain may have to send in troops to support democratic regimes in order for the economy and way of life to stabilise, as was successful in the case of Sierra Leone. Collier recognises four ‘poverty traps’ which need to be overcome before the delicate economy can begin to grow, in order to do so, the poorest nations need our help. Through his research, Collier found that conflict is one of the major traps that are keeping nations in these states, but unlike the worlds media and politicians’ would suggest, this is not necessarily due to especially poor politicians or a ‘uniquely fractious population’ but by poverty. He identifies a shocking threat that in any given 5 year period, the worlds lowest income countries have a 14 percent chance of falling into civil unrest or even war. “Young men, who are the recruits for rebel armies, come pretty cheap in an environment of hopeless poverty. Joining a rebel movement gives these young men a small chance of riches”. And of course, poverty and civil unrest bring about a whole host of health problems and epidemics, with limited healthcare running alongside and even intertwined within these issues, it is no wonder the life expectancy of those in the poorest nations falls well below the happy 80 years we can expect to live to in this country. There is not ex-
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tensive detail about the problems faced by the health of these nations; however, I do urge all those whose concerns lie within this field to read ‘The Bottom Billion’ in order to gain extremely valid insight into the complex tangle that is the situations of these countries. Furthermore, Collier speaks of the ‘headless Heart’ whereby he identifies that well- meaning but essentially misguided campaigners oppose certain measures such as cutting trade barriers or sending in troops which could actually help these countries in the long run. In conclusion, Collier writes for every person who has ever been concerned for
their fellow human beings in the poorest places of the world. He has researched and witnessed the poorest nations struggle for equality through striving for rising economy. He does not write for his fellow economists, using economic terms or examples that might as well be in a foreign language to the rest of us average-Joe’s. He writes with genuine concern, enthusiasm and heart, he is simply trying to inform us of what needs to be done and what can be done. Lucy Reeve Third Year Medical Student
Calendar 4th Novemeber:
Healthy Planet: Climate Change Workship: Climate Change is a defining Global Health issue of the 21st century. 6-8pm Malet Place Engineer 1.03
Multidisciplinary approaches to help tackle infectious disease, 9am The Royal Society of Medicine £35
Neglected Tropical Disease 9am-4pm The Royal Society of Medicine £5 (members) £15 (non-members) Stop AIDs: World AIDs Day Mega Raid 10am for registration and breakfast Contact firstname.lastname@example.org KCL Student Union
Daoud Hari: The translator talk by Daoud Hari, refugee translator, capture & author from Darfur 7pm Christopher Ingold Chemistry Lecture theatre UCL “Darfur Perspective in a region in crisis” panel session chaired by Lord David Alton 7pm-8.30pm Christopher Ingold Chemistry Lecture theatre UCL Infectious Disease & Pensions with Disability from HIV to Malaria & Beyond Seminar UCL Global disability. 4.30pm-7.30pm Wilkins Garden room UCL
UCL Page 26
November: Issue 4 B
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