Issue 1 - UCL Medsin Magazine by Medsin UCL

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

October 2008—Issue 1

Perspectives UCLU Medsin RUMS Society’s Global Health Magazine

AIDS in South Africa The politics of the rhinoceros cure

Diabetes Taking Africa by storm

Indigenous Health A neglected crisis?

Female Genital Mutilation To cut or not to cut?

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Published on behalf of the UCLU Medsin RUMS Society by Davina Patel

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

The Grand Challenge of Global Health

CL’s research strategy has defined four Grand Challenges: those areas in which we are facilitating cross-disciplinary interaction within and beyond UCL and applying our collective strengths, insights, and creativity to overcome problems of global significance.

The first of these is the Grand Challenge of Global Health. Billions of us lack access to adequate food, water, sanitation, medicine and education. Unnecessary suffering, for example through HIV/AIDS and malarial infection, prevails, despite the breakthroughs in medical science that have made it possible to prevent, contain, manage, and eliminate much disease. Solutions to a whole range of health problems around the world are within our grasp, yet societal and natural forces conspire to prolong and extend the destruction of huge numbers of our fellow humans. Our potential UCL has an existing international profile in the major disciplines that are key to addressing barriers to sustainable improvement of global health. These include anthropology, development planning, political science, built environment, law, climatology, human rights, economics and biomedicine. UCL students have played a leading role through Medsin in raising the profile of global health. Our undergraduate programme in international health has raised awareness amongst thousands of students worldwide about global health issues. Exciting opportunities In some ways the opportunity to work across all the faculties of UCL has made the last two years the most exciting of my professional career. Collaborations across many diverse departments are starting to happen and we are launching an exciting new cross-faculty Masters in global health. Also, the extremely popular public symposia, organised by the UCL Institute for Global Health continue (the next will be at 2pm on 24th November on Climate Change and Health and will take place at the UCL Institute of Child Health). I congratulate Medsin on producing this magazine, which is very much in the spirit of the Grand Challenge of Global Health. This is an exciting time for anyone interested in global health at UCL. Anthony Costello Director of the UCL Institute for Global Health If you wish to be included on our email circulars then please send your details to Sarah Ball at s.ball@ucl.ac.uk. Institute of Global Health website http://www.ucl.ac.uk/global-health

Foreword from Medsin UCL CoCo-Presidents Medsin UCL is extremely proud to present the first issue of our new Global Health Magazine: Perspectives. We would like to thank everyone involved in the making of this magazine – the design team, the proofreaders, the writers, the section editors, the core editors, and especially Vishaal Virani, the Chief Editor. We are so glad that there are so many students passionate about Global Health at UCL. "Educate. Inspire. Act" is the motto of the Medsin National Conference 2008, hosted by our own UCL, and as cliché as it may be; it holds a great deal of truth. So we hope that you are Educated by Perspectives; we hope that you are Inspired by Medsin UCL; and most of all, we hope that you Act upon your convictions. And wherever you end up, whatever you decide to do, never forget the immortal words of Margaret Mead: "Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has". Mustafa Abbas and Davina Kaur Patel Medsin UCL Co-Presidents, 2008/2009

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Meet the Team

Contents »

Current Affairs

Letters

Interview

Village Aid

Indigenous Health: A Neglected Crisis

Visual Perspectives

AIDS and the Politics of the Rhinoceros Cure 14

A Place of Refuge

Pregnant in the Land of Gold

Wealthy Pharmaceutical Companies, Unhealthy World

Diabetes Taking Africa by Storm

Globalisation of Medical Research

Female Genital Mutilation

Reviews

Calendar

Scope of Horror

Core Editors Vishaal Virani, Katharine Langford, Katie Birley, Joyce Browne Design Team Ruth Batham, Melania Ishak, Lucy Reeve, Judith Jade, Elena Ferran, Clare Parsons Cover Photo Umar Ahmad - http://www.lightstalkers.org/galleries/ slideshow/15002 Section Editors Aadarsh Shah, Efun Akerele, Elena Ferran, Lucy Reeve, Michael Malley, Natasha Lyons, Rachael Getzels, Rachel Scott, Ragulan Ravirajan, Zaneta Forson, Neal Russell Proofreaders Anna Wight, Charlotte Lightfoot, Emily Savell, Hannah Rees, Karina Pall, Kate McAllister, Nikhil Patel, Nina Grayson Webmaster Joel Cunningham

With special thanks to Mustafa Abbas, Davina Kaur Patel, Rachel Scott and Kate McAllister Please visit our website to view this magazine in PDF format: http://www.uclmedsin.org For full article references see the online version

Letter from the Editor Welcome to the first issue of Perspectives, the new global health magazine brought to you by Medsin UCL. I hope that reading this magazine will inspire you to become more involved with global health issues within UCL and beyond. The fascination with global health, I believe, lies in the multitude of factors that influence health outcomes around the world. The Medsin UCL conference theme of Power and Politics in Global Health underlines this point. I hope this magazine will further highlight to you the impact that culture, economics, and politics, amongst other factors, have on health. This magazine is tangible proof that students at UCL do care about global health and it exemplifies what the student community can achieve if it works together. There is currently a strong global health movement at UCL, facilitated by Medsin UCL and the Institute for Global Health. I encourage you all to consider the ways in which you can contribute to this movement and act upon those considerations. If reading this magazine inspires you to get involved with Medsin UCL, pick up a book related to global health, or just tell a friend about something you learnt from the magazine, then the purpose of the magazine will be fulfilled, and you will have become part of the global health movement. Vishaal Virani, Editor http://www.uclmedsin.org

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Current Affairs

By Michael Malley, Ragulan Ravirajan and Natasha Lyons

Pregnancy and Childbirth – a postcode lottery on a global scale A woman will die during pregnancy or childbirth whilst you read this article (assuming you don’t take longer than a minute to do so, in which case the figure will double). If you don’t have a calculator handy, that works out to over half a million women dying every year. What’s worse, the vast majority of these individual tragedies are readily preventable with access to basic medical care. The alarming statistic is that 99% of maternal deaths in pregnancy or childbirth occur in the developing world1, half of them in sub-Saharan Africa. This is the equivalent of a postcode lottery on a global and deadly scale – a postcode in Niger will give a mother a 1 in 7 life-time chance of dying in pregnancy, whereas in Sweden the figure is 1 in 17400, UNICEF reports2 The good news? This massive disparity is gaining publicity at the highest levels. There is increased political pressure to deliver the fifth Millennium Development Goal – to reduce maternal mortality by 75% before 2015. Sri Lanka and Mozambique are two countries tackling this problem with some success. Their tactics include a greater emphasis on family planning and maternal education. The United Nations Population Fund believes that adequate contraception provided to those seeking it could prevent one third of maternal deaths, by spacing pregnancies more effectively and ensuring that every pregnancy is wanted3. However, a crucial component remains the training of more skilled birth attendants as currently only 2 in 5 births worldwide are attended by skilled personnel. A greater political will to supply contraception and train skilled personnel would enable significant progress to be made in turning a post-code lottery into a post-natal success.

“Polypill” nears reality The question is what’s better for cardiovascular health than taking a combination of tablets, which thin the blood, lower cholesterol and lower blood pressure? The answer may be taking one affordable tablet which does all three! The “polypill” is just that, and has been in the pipeline for several years. However, few financial incentives exist for drug companies to produce it – a month’s supply may cost as little as $1. Despite this, the pill, which includes aspirin, a cholesterol-lowering statin and two antihypertensives, began clinical trials this month. It is supported and funded by the Wellcome Trust and the British Heart Foundation, and according to a paper in the BMJ, could prevent up to 80% of heart attacks and strokes in Britain5. Some questions concerning exactly who receives the pill and the cost of prescribing it on a large scale remain. However, if successful, larger trials involving thousands of subjects could begin next year. The potential benefits of such a pill extend beyond Britain, with some advocating the use of the polypill “almost blind” to everyone over 55 in the developing world6. The WHO says 17 million people die prematurely from heart disease and stroke each year, the majority of whom live in low or middle-income countries7. The polypill doesn’t quite fit the “magic bullet” category of medicine, but could prove to be a cheap way to improve the cardiovascular health of people on a global scale.

Mugabe’s Mayhem Despite the United Nations Children’s Fund’s (UNICEF) initiation of a large-scale health campaign in Zimbabwe over the last two months, the organisation expressed concern over the government’s ban on non-governmental organisations (NGOs) in remote, rural regions of the country. UNICEF had been involved in addressing severe vitamin deficiencies and implementing vaccination programmes for children against tuberculosis and polio in various regions of Zimbabwe. Vitamin A supplementation was distributed throughout the population in order to prevent deficiency, a major health problem affecting this Southern African country of 12 million people. However, after imposing the ban, Zimbabwe’s two million children under the age of five no longer have access to vitamin supplements and immunisations, leaving them more susceptible to infectious diseases and growth defects. The organisation has now expressed concerns over the welfare of children residing in areas such as Matabeleland and Mashonaland, where NGOs have been banned from operating.

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October 2008 - Issue 1

It is widely thought that President Mugabe instigated this ban based on his belief that NGOs were being used by the United States and the European Union to destabilise the country and distribute pro-West propaganda. However, this has backfired immensely and resulted in further civil unrest, especially between the two main political parties, Zanu PF and the Movement for Democratic Change. The fragility of the recent power-sharing deal between these old foes, and its predicted failure, may well further exacerbate this precarious situation. Meanwhile Sri Lanka's government has recently prohibited all foreign aid workers from operating in the Tamil-rebel held areas in the North. The defence secretary Gotabhaya Rajapaksa reasoned that the government could not guarantee the safety of aid workers in the Northern region of the island, especially the densely populated Vanni district. The United Nations and the International Red Cross, both of whom have been operating in the North and East of the country for the last fifteen years have estimated that over 160 000 people have become displaced and a further 85 000 people have fled their homes due to military offensives which escalated in June 2008. They predict a humanitarian disaster if the government does not reverse the ban on aid workers. Furthermore, the UN has described Sri Lanka as one of the world’s most dangerous places for journalists. This means that any humanitarian crisis in this region would remain largely unreported to the outside world.

Food crises – failing to prepare is preparing to fail It may appear difficult to respond to crises that aren’t actually happening. That’s fair enough. After all, there would be few emotive media pictures, little immediate international pressure and unfortunately in our current world, a crisis inevitably happening somewhere else already. However, it is argued that far more effective international aid can be given before a food crisis than during it. A recent report from CARE International (an aid agency) underlines this point, highlighting the generous response of donors to the current Ethiopian food crisis – donors who only months earlier rejected a plea from CARE to prevent a food emergency in the Horn of Africa. CARE also suggests a new global fund be instigated to deal preemptively with a heightened food crisis and believes money must be spent making people and their lifestyles more resilient to future difficulties, thus safeguarding food supplies. CARE says that 100 million people have been tipped into ‘destitution’ in the last two years alone by the global food crisis4 and the U.N. estimates the world’s hungry totals 925 million people – food for thought indeed.

Image from UNICEF USA

Yet channelling any resources away from immediate and tangible food crises is no easy matter however great the future benefits might be. The temptation is always to spend whatever money becomes available here and now. It begs the difficult question - should available resources be spent helping those immediately in need (which currently number up to one sixth of the world population), or in preventing future unknown persons from experiencing similar problems. Ideally, aid would provide for both, yet the situation in reality is far from ideal. A balance needs to be struck and cannot be achieved without greatly increased investment and making some potentially difficult choices. One thing is for certain - as the co-author of the CARE report declares, “Doing nothing is not an option”.

You couldn’t make this up... Danger Dentist: In the Bavarian town of Neli-ulm, a German dentist stormed into the house of a female patient to forcibly remove her braces. The patient had been unable to pay her £320 bill and reports that the dentist did not say a word throughout the oralassault. Trickster Tumour: Surgeons in Japan have removed a 25-year-old towel from the stomach of a 50year-old man, thinking that the suspect lump was a tumour. It is thought that the towel was left inside the man during an operation he had had on an ulcer. Horse Anyone? A man rode a horse into Wilcox Memorial Hospital in Hawaii in order to cheer up a sickly relative. He took the horse up to the third floor in the lift, only to be confronted by members of staff, who informed him that he and the steed had to leave. The man reportedly protested that the hospital had a ‘pets visitation policy’, but was told that this was only for dogs and cats.

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global news o global views

Letters Arms for Georgia and Russia supplied by Britain The recent conflict in South Ossetia has caused the deaths and displacement of large numbers of people. Can it be a coincidence that in the last year Britain’s sales of military equipment to Georgia and Russia escalated by over 8-fold and 10-fold respectively? From 2005 to 2007, British military sales to Georgia increased from £250,000 to £5.4m, and sales to Russia increased from £5m to £55m1. This is just a needle in the haystack of global arms sales that sustain conflicts which are responsible for millions of civilian deaths around the world. So, where does the blame really lie for the conflicts in the world? Neal Russell, Medicine, UCL Democratic Republic of Congo—Not important enough? Some have described it as being the “world’s deadliest crisis since World War II”, but the Democratic Republic of Congo (DRC) is very rarely in the news. A recent estimate put the number of deaths directly and indirectly due to conflict in DRC at 5.4 million1. This is significantly higher than the number of deaths caused by the war in Iraq or the tsunami in South East Asia – two recent global crises. Yet the amount of humanitarian aid given to DRC is dwarfed by the amount given to Iraq and South East Asia. It would appear that the international community is not responding purely based on humanitarian need. One factor is that people in the DRC have been dying slowly over many years, in a way that is not suited to great media attention, but the other problem is that the West doesn’t have enough political, economic or security interest in DRC. Of course, the Tsunami in South East Asia and war in Iraq deserved every penny of humanitarian aid they receive, but couldn’t there be a proportionate response to places like DRC? Unfortunately DRC isn’t in many travel agent’s brochures or government’s economic agendas! Melissa Palmer, Human Sciences, UCL

What would the Conservatives do for Global Health? In the next few years there will have been elections in both the US and the UK, two powerful countries that can significantly influence global health. A recent article in The Lancet1 compared the US presidential candidate’s stances on Global Health but what about the UK? If current public opinion continues as it is at present, the Conservatives will be in government within the next few years, but what would they do for Global Health? Unfortunately this is difficult to know as, unsurprisingly, international development is not on the list of priority policies on the Conservative’s website! Indeed, international development really isn’t an election issue. I doubt if many people vote based on the aid policies of each political party! It may be that there would be little difference between the Conservatives and the current Government. Nevertheless, what can we expect from the Conservatives abroad when they haven’t even committed to child poverty reduction targets in the UK Andrew Strang, History, UCL

"Of all the forms of inequality, injustice in health care is the most shocking and inhumane." Dr. Martin Luther King, Jr.

China—The Olympics looked great but what about health? The Olympics were an impressive symbol of China’s rapidly increasing wealth, but is similar success reflected in China’s record on healthcare? Much of the western media portrays China’s recent history as a great progression towards a more open and prosperous country (except for the human rights bit!). The reality in terms of health has been slightly different. In fact, since China liberalised and embraced a free-market, capitalist model in the 80s and 90s, its rate of improvement in infant and under five mortality rates has slowed, despite greatly increased economic growth. It seems that China has kept all the “bad” parts of its past (such as lack of democracy), but left behind “good” parts, such as access to primary health care. Matthew Farrant, Medicine, UCL

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

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October 2008 - Issue 1

The Interview: Trust me, I’m an Anthropologist Melissa Leach, anthropologist and director of the STEPS centre, talks to Rachel Scott about the importance of research in the global health field

s Melissa Leach greets me outside her office at the University of Sussex Institute of Development Studies, I have to admit I am a little in awe. She took a rather direct route to her career in global health, graduating with a first in Geography at Cambridge, where she discovered her affinity for the human aspect of the subject, followed by a Masters in Anthropology at SOAS, and then a PhD. In 1990 she became a fellow of the Institute of Development Studies at the University of Sussex. Now 43, she is also director of the STEPS Centre (Social, Technological, and Environmental Pathways to Sustainability), which describes itself as a new interdisciplinary global research and policy hub. It aims to challenge the top down, “one-size-fits-all” approach to policy implementation, and the design of solutions for a stable, unchanging world. The world, in reality, is always changing, and policies need the capacity to adapt to these changes.

of political, bureaucratic and funding pushes, without sufficient capacity to listen to research and pause for reflection”. One Size Does Not Fit All Global health, she believes, is a field where “there are some real tensions at stake”. On the one hand, she says, “there is an increased appreciation among [health professionals] of the importance of social realities and interdisciplinary approaches”. However, on the other hand, emergent foundations, such as the Bill and Melinda Gates Foundation, with “top down programmes expecting quick wins and …measurable impact”, lead to the risk of a return to a model of one-size-fits-all standardised responses. A social scientist through and through, she maintains that this in itself is an interesting phenomenon to study, but can also be frustrating, as “they are actually taking us away from some of the lessons that have been learnt over the years in terms of what works in international health”.

Think Locally, Act Locally An anthropologist at heart, Leach tells me that the most enjoyable part of her work is Leach asserts that some sort of the “in-depth, on the ground research” that practical experience is “critical” to she is able to carry out with people in often working in global health research, and remote places, and which has enabled her to that there is no substitute for the travel widely. It is important, she says, to insights that it provides into problems understand the “local realities of peoples’ “as they are lived and experienced by experiences and ways of thinking about people who are materially poor”. For health-related issues”, which are “often any career with a research linkage a counter to dominant biomedical received PhD can also be very useful. It gives an wisdom, but …very logical”. opportunity to study in depth and She explains how rewarding it can be to use Image from http://www.steps-centre.org become an expert, giving one “a this locally received knowledge to redirect dis tinc tive con tribu tion to a projects to work better on the ground. Her most recent book, competitive field”. Although the STEPS Centre celebrates its Vaccine Anxieties: Global Science, Child Health and Society, interdisciplinary credentials, she advocates a grounding in a examines how parents in different societies understand and engage particular discipline, be it in the life or the social sciences, before with vaccination. An example given is that of opposition to the polio vaccine in Nigeria, because of the belief by the Muslim going on to do an interdisciplinary masters or internship. The population that it was deliberately infected with anti-fertility development world, she says, is “full of buzzwords”, and it is agents and the HIV virus. Whilst this may seem irrational, it must beneficial to have the confidence that comes from a particular take on an issue as well as the flexibility to listen to other people’s be taken in the wider context of 9/11 and recent foreign policy points of view. toward Islamic countries.

Rachel Scott is a 3rd year Human Sciences undergraduate,

Working in research and policy engagement seems to leave one in interested in different perspectives on and approaches to the favourable position of working neither in grassroots practice international health and development. nor policy implementation, yet influencing both. In providing the evidence to connect these two branches, research has the capacity To find out more: Visit the STEPS Centre website at http://www.steps-centre.org to “inform both [policy makers and practitioners]…, and encourage both… to think differently” says Melissa. However, she Read “Vaccine Anxieties: Global Science, Child Health and Society adds that the agility of this hybrid position can be negated by the - Beyond Risk” by Leach, M. and Fairhead. J feeling that sometimes “policy just moves the way it moves because

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Want a career that makes a difference? Don’t wait – now’s your chance This summer, Nina Grayson has been volunteering at Village Aid, an international development charity in Derbyshire, and discovering that charity work isn’t all about second-hand knitwear.

s summer term was drawing to a close and I was trying to plan what to do back home for four long months, I decided to look into charity internships; now seemed like a good time to gain experience in a field I hope to work in after graduating. I discovered Village Aid on www.doit.org.uk, the only national database of volunteering opportunities. I was drawn to them as they were based close to home but worked overseas, unlike most of the other local charities I’d looked into. Village Aid works with partner organisations in rural communities in five West African countries, giving local people the resources and skills needed to break free from poverty brought about by injustice and marginalisation. One key element of their work is REFLECT adult literacy circles. In these groups participants learn functional literacy, which first enables them to deal with domestic matters independently and will hopefully lead to increased participation in community matters, fostering gender equality and a more democratic process. Women often face discrimination, for example, if widowed, a woman may be vulnerable to poverty and homelessness if she is unable to assert her right to inheritance - so Village Aid has A map of where Village Aid operates begun work with Abanbeke Development Association (ADA), an organisation in Nigeria that tackles the social exclusion of vulnerable people by lobbying on behalf of women's rights and providing micro-credit and agricultural training to severely impoverished families. Micro-credit involves providing small loans to those who are struggling. The cash enables them to invest in opportunities such as cooperatives and small business ventures that will help them to secure a sustainable and independent future, which is especially important for single mothers. Although ADA was founded in 1986, last year was the first time it received international support, which has greatly increased the services it can provide. 88 young mothers are now able to pay their children's school fees and 40 small retail businesses have been established. Applying to charitable trusts is one way that Village Aid funds its work. In August this year the Rufford Maurice Laing Foundation granted the charity £3000. With this money, a range of strategies will be implemented to allow women to be recognised as valuable members of their communities. Targeting influential people, such as chiefs, is one such strategy. Chiefs are community leaders and advisers, so they often have very influential roles in maintaining and changing opinion and are therefore crucial in dispelling negative views about women. This grant will also allow the provision of organic agricultural training so that the environment will undergo fewer stresses on its resources, thereby improving food reliability and in turn reducing health problems. In addition, the grant will fund functional literacy training through REFLECT.

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Whilst grants like this are fantastic for improving the quality of support and length of commitment to a partner organisation, Village Aid can only continue to thrive long-term if it receives regular funding, which is why Jo Williams, Village Aid's donor development manager, was about to launch the Africa Matters appeal when I began volunteering. Through this two-year appeal she wants to raise awareness and a crucial £100,000 to ensure the charity’s sustainability and enable new projects to be supported. I had previous experience in fundraising from my job as a street It's great to do voluntary fundraiser, so I have been developing the schools' fundraising pack and designing resources. Village Aid already works closely with children in the local area, running free drama work that you actually enjoy; workshops and providing resources to schools, so now we need them to help us. I have also there's nothing wrong with been writing press releases to increase public awareness, and contacting existing supporters getting something out of it to establish local groups who can hold fundraising events in their communities. I have done much of my work from home as this has enabled me to find paid employment too and I can yourself! now use my experience at Village Aid to help me in future employment; I have used and learnt many skills such as confidence in talking to people over the phone, researching for the schools’ packs and getting first-hand experience of how a charity works, especially regarding funding and marketing.

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I have really enjoyed getting involved with this charity and their work is incredibly worthwhile. It’s great to do voluntary work that you actually enjoy; there’s nothing wrong with getting something out of it yourself! I have gained some valuable experience that I hope will boost my chances of getting a paid job in international development or journalism in the future. For Village Aid’s beneficiaries, learning is crucial in bringing about positive change and working with them has taught me one thing above all - if you’re a student wanting to have a career that makes a difference, don’t wait. Start making that difference now. To find out more: For more information on Village Aid, the Africa MatNina Grayson is studying Anthropology at UCL and is interested in issues ters appeal or how your talents can be put to use with in developing countries such as barriers to health and minority rights. Village Aid, please contact Jo on 01629 814434, email jo@villageaid.org or visit www.villageaid.org Thank you to Jo Williams of Village Aid for permission to reproduce the images.

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Indigenous Health: A Neglected Crisis Molebedi Segwagwe describes how colonialism and capitalism have conspired to damage the health of Indigenous populations in many countries

hrough capitalism and colonialism, great inequities were created and continue to persist in the global and local distributions of wealth. This is reflected worldwide in the health outcomes of the haves and the have-nots. Indeed, at the level of individual countries, it is evident to see that Westernisation has rendered most nonindigenous populations healthier and generally more prosperous than their Indigenous countrymen.

Some argue that Westernisation inevitably leads to economic Darwinism1, with the divergent health outcomes of the rich and the poor simply a result of this financial scramble. However, for healthcare professionals who feel morally obligated to treat all social classes regardless of wealth, The Bushmen of Botswana (Picture from http://www. notanmba.com/) this argument is insufficient. There are 370 million indigenous people across 70 countries2, thus Indigenous health is a big issue. society, thus vocal Land Rights campaigns new resettlement camps in the Ghanzi and active protests are a common defining district. The government argues it is easier Who are the Indigenous and Are they feature of the Indigenous4. to provide health-improving services such as Really Unhealthy? clean water for the Bushmen when they are The health problems affecting Indigenous resettled8. The non-governmental Indigenous people are most commonly populations vary according to geographical organisation (NGO) Survival International defined as those people who inhabited a location, but several seem to be globally questions the veracity of this explanation9, recurrent. Indigenous people are afflicted perhaps with good reason as Bushmen disproportionately by alcohol and territory is rich in reserves of copper, nickel substance abuse issues. Child sex abuse, and diamonds which are key export â&#x20AC;&#x153;There are 370 million depression, unemployment and the commodities for Botswana10. Bushmen indigenous people across 70 breakdown of traditional family units are homelands are also part of the Central Kgalagadi Game Reserve, an important countries, thus Indigenous significant problems too6. These factors collectively contribute to higher suicide tourist destination and source of revenue for health is a big issueâ&#x20AC;? rates, for example the Canadian Inuit the country. population's suicide rate is 11 times higher Relocation of the Bushmen has left them than the Canadian national average7. country before its colonisation by migrants3. Indigenous people are also thought to fare unhealthier and unemployed. Levels of Governments frequently inflict political and worse in classic health measures such as alcoholism have risen drastically leading to economic subordination on their increased incidents of violence against infant and maternal mortality, though a Indigenous populations giving them little women. Although the prevalence of HIV/ paucity of data exists in these areas5. control over the policies that decide their AIDS has historically been lower in the fate4. Indigenous people are also prone to Bushmen compared to the total Botswana Out of the Bush, Into the Fire forceful removal from their traditional population8 there are reports of rising HIV lands. These lands are then exploited by the The Indigenous people of Botswana are the incidence in the resettlement camps. It is government for various profitable Bushmen. Their current plight stems from a thought that the traditionally isolated and endeavours from which Indigenous people government policy to relocate them, from scattered nature of the Bushmen had do not benefit5. Landlessness has profound their traditional land of 27,000 years, to protected them from the disease. However, economic and cultural effects on Indigenous intimate relationships with the

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October 2008 - Issue 1

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“The Indigenous health problem is a direct result of colonialism and capitalism” Tswana population in resettlement camps are now causing increased HIV transmission8. In 2006, the Bushmen won a landmark ruling condemning their forced relocation as 'unlawful and unconstitutional', which gave them a mandate to return to the Kgalagadi. The government has appealed this judgement, and so for now the Bushmen remain in the resettlement camps9. Colonialism and the Aboriginals of Australia Of all countries, Australia experiences the largest disparities in life expectancy between Indigenous and non-indigenous populations11. The source of this inequity is the colonial history of Australia. The British descended on Australia in the 1700's, declaring the region uninhabited despite the fact that Indigenous people had occupied the land for over 40 000 years12. Struggles for territory led to open war between the Indigenous and the colonialists. This resulted in a severe depopulation of the Indigenous, who could not match the might of British imperialism12. The prevailing discourse of the British colonisers described the Aboriginals as a “dying people”. This led to lack of investment in Indigenous health and Indigenous people had no civil rights. Social securities such as pensions and sickness benefits were the exclusive preserve of white Australians5. Even today there remains inequity in the amount of money spent on Indigenous peoples' health compared to white Australians; the average public health expenditure on each Indigenous Australian in 2001-2002 was only 39% of that spent on each white Australian13. The result is an Indigenous Australian population with three times the morbidity rate of their white counterparts13. As well as high Tuberculosis and Hepatitis B rates, the Indigenous have an increased genetic predisposition to development of obesity

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and diabetes, brought about by newly introduced Western diets they did not evolve to consume12. There are encouraging elements to this story. Indigenous Australians have been able to set up clinics providing culturally sensitive healthcare for themselves. Medical schools now also set aside a particular allocation for training Indigenous students who will then provide healthcare to their own communities12. This model of autonomy is perhaps one that Botswana's Bushmen should follow to improve their own health.

to be the remit of NGOs such as Survival International. The WHO and these smaller scale, local organisations must work together to improve the welfare of Indigenous peoples. The DoubleDouble-Edged Sword of Capitalism

The Indigenous health problem is a direct result of colonialism and capitalism. The initial colonisation of Indigenous homelands by foreign populations meant destruction of traditional social orders and legacies. This left Indigenous people considerably weaker than they were precolonisation. Capitalism involved the In 2006, the Australian Prime Minister stealing of territories for economic benefit Kevin Rudd offered an apology for the by colonising forces, leaving the Indigenous “profound grief, suffering and loss” caused people homeless and destitute. Poverty is to Australia's Indigenous people by universally recognised as a cause of disease colonisation14. Whilst this new recognition and it is obvious the effect it has had on of a great historical injustice is promising, it indigenous health. remains to be seen if any real effects will reach Indigenous people in terms of In addition, the lack of investment in improved health and social outcomes. Indigenous healthcare services by colonising forces, which often considered the native Where Are The WHO? population as inferior and not worthy of attention, compounded the effects of The World Health Organisation (WHO) poverty and further ruined Indigenous aims to improve Indigenous health by health5. The result nowadays is that focusing on five main strategies: Raising Indigenous populations are poorer, sicker awareness of Indigenous health issues via an and less populous than they were preincreased number of publications, colonisation. conducting workshops for healthcare workers on Indigenous health, exposing health disparities by analysing data and looking at variables that are specific to Indigenous people such as ethnicity, integrating Indigenous health into the Millennium Development Goals and acting to improve Indigenous people's human rights6. A large problem facing successful execution of the WHO's policies is the lack of published data collected on Indigenous health issues. This is partly due to the scattered nature of Indigenous communities, and partly because of political inertia. This paucity of data makes it difficult to assess the effectiveness of any policy created by the WHO or other agencies6. The WHO's role in this issue is mainly focussed on providing guidelines and information related to the health issues affecting Indigenous people and less on direct action at grass roots level. This seems

Picture from http://cache.eb.com/

Recent focuses by governments, for example in Botswana, on modernization and ushering Indigenous people into the 21st century have actually caused, not alleviated, sickness and poverty. The problem with these paternalistic policies is they do not

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine take into account the desire of Indigenous people. It must be questioned whether Indigenous people actually want to be Westernised.

the creation and implementation of more evidence based policies.

Capitalism can be effective in pulling countries out of poverty and into It is evident that a new direction is needed prosperity. However, capitalism must not be in Indigenous Health. The WHO suggests allowed to destroy the health of 370 million a human rights based approach6 that people – can we not have economic emphasises conservation of traditional ways progress and also protect the welfare of of life and self-determination. Governments Indigenous people simultaneously? This is must be urged to collect more data on the the challenge facing Indigenous health. health of their Indigenous peoples to allow

Molebedi Segwagwe is a 2nd year University of Sheffield medical student intercalating at UCL with an interest in the health effects of capitalism on the poor

To find out more: Read “The Health of Indigenous Australians” by Neil Thomson Read “Health care in indigenous populations: the Xingu Indian park” in The Lancet 2003; 362:s38-s39 Read “The health status of indigenous peoples and others” in the BMJ by Ring I. Brown N. 2003; 327:404

Visual Perspectives (Right) In preparation of the entry into womanhood and marriage, the Masaai have a special ritual for girls which involves a multiple day celebration, ending with the circumcision (by making a incision into the clitoris or a clitodectomy). The shaving of the head is symbolic in a Masaai woman's life for many occassions, including here as one of the final rituals before the circumcision. Taken by Joyce Browne

(Above) The Masaai have an old and elaborate system of traditional medicine. Here, the traditional healer is explaining the use and preparation of different natural medicines found in the Masaai' environment. He demonstrated medicine for malaria and other diseases. Taken by Maartje Melse

(Left) Pilgrims gathering in Haridwar, the holy city near the source of the River Ganges in India. Millions bathe in the waters of the Ganges every year but there are serious concerns over the safety of this custom. Dysentery and cholera are just of two of the many diseases that can affect bathers. Yet the religious power of the river keeps pilgrims and tourists alike coming back year after year. Taken by Vishaal Virani

Please send in your photos with a caption to medsinmagazine@gmail.com to be published in the second issue 12

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Medsin UCL’s Global Health Magazine

AIDS and The Politics of The Rhinoceros Cure

n 26th September 2008 Barbara Hogan became the Health Minister of South Africa in a reshuffle following the resignation of President Thabo Mbeki. She is entrusted with the task of steering HIV/AIDS policy in a

The battle between traditional and Western medicine in South Africa is undermining AIDS management. Luke La Hausse explores this conflict of interests

Africa, as the economic powerhouse of the region, would be better equipped than its neighbours to tackle this devastating infection. Instead, South Africa is engaged in a debilitating struggle over how to deal with HIV infection involving the competing claims of traditional and Western medicine. Garlic and Lemon The climate of confusion has not been helped by the uncertainty at the heart of South Africa’s leadership. Former Health Minister Dr. Manto TshabalalaMsimang repeatedly condemned anti-retroviral drugs (ARVs, the gold standard treatment for HIV infection), and warned of their ‘toxic’ side effects. Comments from Msimang such as “Raw garlic and a skin of the lemon … protect you from disease.”4, in 2005, led to South Africa’s approach to the epidemic being branded “lunatic” by UN special envoy Stephen Lewis in Toronto5.

new direction in the wake of years of domestic and international criticism of South Africa’s response to the disease. Across the country it is estimated that around 5.7 million people are infected with the HIV virus1, yet by the end of April 2008 the availability of essential medication was limited to only 478 000 individuals2.

Such anti-ARV sentiment feeds suspicions about Western medicines in a country whose people still retain a deep reverence for ancestor guided traditional healing. As health officials push for greater incorporation of traditional medicine into the healthcare system there are fears that effective treatments for HIV are being sidelined.

consult one of 200,000 traditional healers in the country6. The care provided is culturally sensitive and the healers themselves trusted and respected within their communities making them potentially powerful partners in the fight against HIV. The World Health Organisation recognized this and in 2002 launched its Traditional Medicines Strategy. The strategy aims to promote safe and effective traditional therapies, and acknowledges that such care “could become a critical tool to increase access to healthcare.” Crucially, however, this document acknowledges the “paucity of

Across the country it is estimated that around 5.7 million people are infected with the HIV virus data” relating to traditional medicines, one that continues to be of great concern to practitioners of allopathic (Western) medicine7. In an attempt to address this dearth of knowledge, scientists at the University of Cape Town have undertaken an ambitious project to form a Traditional Medicines Database. It is estimated that of South Africa’s 24,000 terrestrial plants, 4,000 have medical significance. This holds promise for the discovery of novel therapeutics8.

Traditional Medicine Rhinoceros Cure

In 2007 the region of Southern Africa accounted for 32% of all new HIV infections and AIDS related deaths globally3. One might imagine that South

Traditional medicine forms the cornerstone of informal healthcare in South Africa and it is estimated that when ill, 80% of South Africans will initially

Zeblon Gwala is an entrepreneur who has sought to address the current confusion over AIDS in South Africa. The

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine well-heeled former lorry driver has been marketing a herbal remedy that he claims cures AIDS9. The origin of Gwala’s concoction, known as uBhejane (Zulu for black rhinoceros), is almost as astonishing as his claims about its restorative effects. He describes how in his former job he would, whilst driving, “dream of different herbs” and he would “write down what he [had] dreamt of.” He continues his story “my grandfather was a traditional healer, I was not a traditional healer but I kept dreaming of these herbs. When I had finished [dreaming], [my grandfather] then told me what the medicine was for.” The medicine is supplied in 2-litre plastic milk bottles and comes in two parts: a white- capped bottle to “boost the immune system” and a second blue-capped bottle to “fight the virus [HIV] or whatever disease you have.”10 Gwala’s agents advise that his medicine should not be taken alongside conventional ARVs. Preliminary studies at the University of KwaZulu-Natal in Durban have shown this blend of 89 African herbs to be nontoxic, but its claimed curative effects are not currently supported by the evidence. Despite this Gwala’s business is booming in many AIDS- ravaged communities in South Africa More disturbingly, until recently, the South African government had provided tacit support for Gwala’s business. In February

The “cure” for AIDS Image from Kanya Ndaki/PlusNews 2006 the Health Department stated that it would “continue to support the research and development of traditional medicine and promote the consumption of food

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In Dr. Rath’s opinion, ARV’s are toxic and actually weaken the immune system, perpetuating unnecessary infection

Vitamin Enthusiasm

In a quest to stamp out what it regards as bad science the TAC, joined by the South African Medical Association (SAMA), has recently delivered a blow to another protagonist in South Africa’s AIDS war, Dr. Matthais Rath. The German born and educated ‘world-renowned scientist and physician’15 has been prevented from further promoting his multivitamin remedies and conducting unlawful trials of vitamin pills on HIV positive patients following a court products that assist in strengthening the immune system,”11 in response to allegations case brought by the TAC and SAMA. Rath, by the Democratic Alliance party that alongside Dr. David Rasnick, an AIDS uBhejane was a “fake AIDS cure.” Several denialist and one-time adviser to the former months later in June, after suggesting that South African president Thabo Mbeki, was some ARVs cause cancer and again conducting illegal clinical trials in Khayelitsha, a township outside of Cape defending uBhejane, Health Minister Tshabalala-Msimang said, “let's rather stick Town. Very poor HIV-positive individuals to traditional medicine.”12 were recruited to attend Rath’s clinics by his agents and were then prescribed courses TAC Attack of up to twenty vitamin pills daily whilst simultaneously being encouraged to give up Since 1998 the pressure group Treatment ARV treatment16. Action Campaign (TAC) has been The Drug Cartel Conspiracy successfully lobbying the South African government, primarily to widen access to The central tenet of Rath’s argument ARVs. More recently the activists’ energy has been directed at holding Mr. Gwala to against antiretrovirals is that behind these drugs stands a multi-billion dollar drug account. The TAC complained to the Advertising Standards Authority of South cartel that offers remedies that are not only useless but actually cause disease thereby Africa (ASASA) after the entrepreneur perpetuating epidemics and providing a placed a newspaper advert in December 2007 claiming that ‘this herb increases your voracious market for the drug companies’ CD4 count (white blood cells attacked by wares17. He maintains that the reason he faces so much opposition from the TAC the HIV virus) and reduces the viral load and SAMA is that these organisations are until it disappears.’13 Further claims were closely allied to the multi-national made about the potion’s ability to treat, amongst other conditions, cancer, sore feet pharmaceutical companies whose profits would be threatened if the healing and pneumonia. In April 2008 ASASA properties of his vitamins were to be ruled that Gwala was under obligation to recognized. In Dr. Rath’s opinion, ARVs hold ‘independent verification from a credible expert in the field of all the claims are toxic and actually weaken the immune made in [his] advertising’ which he failed to system, perpetuating unnecessary infection. do14. In the light of this contravention, the authority upheld the complaint of the TAC There is no question that the ARV therapy and forced the immediate withdrawal of the can indeed cause unpleasant side effects, notably redistribution of body fat and bone advert. death18, but the cost of no ARV treatment is objectively greater. The dissident views of This represents a small victory for those Dr. Rath have arguably supported a lack of who are concerned by the ever-growing market in fake and dangerous HIV ‘cures’. consensus within government and further delayed the distribution of ARV However, in targeting Zeblon Gwala, the TAC had simply been attacking a symptom medication by a dithering Health Department. of general tolerance of unregulated traditional treatments for HIV within the South African Department of Health.

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine Reasons for Hope The TAC and the SAMA continue to oppose dangerous and untested remedies, but it would seem that until the Health Minister and her department start listening to their doctors, scientists and activists and discuss with traditional healers the importance of continuing ARV treatment, the delivery of much needed medication will be obstructed. It must be made clear to the general public that ARVs remain the best way to control HIV infection. The mixed messages of recent years continue to trouble many South Africans who do not know whom to trust. Former President Thabo Mbeki’s historic rejection of the link between HIV and AIDS sowed the seeds of doubt in the public’s mind. Dr. TshabalalaMsimang’s infamous promotion of olive oil, beetroot and garlic as a treatment for AIDS compounded the problem. In addition her statements such as, “We should guard against being bogged down with clinical trials”19 in reference to traditional medicine leaves the door open for further controversial cures. Hopefully that door is now closing and perhaps there are grounds for optimism. UNAIDS (Joint United Nations Program

on Africa a reality. The appointment of new health minister Barbara Hogan is certainly a cause for optimism. It remains to be seen how her appointment will affect AIDS policy in South Africa, however, she affirmed in a press conference on 2nd October of this year that the time for "cheap solutions" and "political games" was over22. Luke la Hausse de Lalouvière, born in South Africa, is a third year medical student whose deep interest in HIV/AIDS in the country stems from his experience of KwaZulu-Natal clinics and hospitals.

Former Health Minister, Dr. Manto Tshabalala-Msimang. © AP Photo

HIV/AIDS) reported this year that there is evidence of a slight decline in the AIDS epidemic affecting some Southern African countries, and that in others the epidemic has either reached or is approaching a plateau20. Furthermore, the £260 million21 worth of ARVs ordered in June by the Health Ministry should continue to widen access to and make government-backed and evidence-based treatment of HIV in South

To find out more: Get involved with the Medsin UCL ‘Student Stop AIDS’ campaign. Visit www.uclmedsin.org/stopaids.htm for more information Read “The African AIDS Epidemic: A History” by J.Iliffe Read “The Invisible Cure” by Helen Epstien (see review on page 29)

Who we are The ‘Student Stop AIDS Campaign’ is a nationwide group of university students who want to do something about the HIV/AIDS pandemic. What we do We have been actively campaigning together since 2003 to force action from the UK government, and other world powers, to stop the devastation caused by AIDS. How we do this • Lobbying the UK government and Members of Parliament. • Undertaking education and awareness raising activities. • Fundraising for charities. The focus for 2008/2009: Patent Pools The campaign will be promoting patent pools - a simple system where drug companies give their patents to a central organisation this allows cheaper generic versions of HIV/AIDS drugs to be produced whilst the company still receives a fair royalty. Contact us. www - http://www.stopaidssocieties.org.uk/ & http://www.stopaidscampaign.org.uk/ email - stopaidsucl@gmail.com

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How to avoid being struck off… Wherever you are in the world, the chance of being removed from the medical register is a clear and present danger. Sara Williams chats to MPS Medicolegal Adviser Dr Richard Stacey about how to avoid being struck off. Even as a student, medical regulatory bodies, like the GMC, expect doctors to be fit to practise and take unethical and unlawful behaviour very seriously. In the UK, Medical Schools all have ‘fitness to practise’ procedures, which mirror those of the GMC. The Medical Act (1983) allows the GMC to consider matters that occurred before a practitioner was registered, i.e. when they were a student. Below is a list of the ten most likely ways to be erased from the medical register. Dr Richard Stacey deals with cases like these every day. He offers advice on the common difficulties experienced by students and junior doctors, and how to avoid being struck off.

Even the best doctors slip up

1. Ignoring your professional responsibilities to your patients

Dr Richard Stacey – Your first duty is to your patients, this may mean that you have to occasionally work beyond the end of your shift. 2. Altering or not making adequate records (including improper signing of certificates RS – Your notes will form the basis of your defence should you be the subject of a complaint or claim. Clearly state the date and time the note was made and do not tamper with the original notes, remember computer notes are audit trailed. Make sure any forms that you complete are factually correct and (where relevant) the information can be corroborated by the medical records. 3. Indecent behaviour towards patients or colleagues (including improper sexual relations with patients) RS – Be aware that patients may mistake inadvertent touching as being improper; e.g. during the course of a fundoscopy beware of any loose clothing touching the patient. Be careful when applying/removing a blood pressure cuff as it can inadvertently touch the chest area. You must follow the Trust’s chaperone policy. Always explain what you are going to do and why. 4. Breach of confidentiality RS – Beware of inadvertent breaches of confidentiality (e.g. “corridor talk”). Your professional responsibility remains, even when off duty. 5. Make false claims about your qualifications or experience RS – You should complete all application forms in a factually accurate way and be able to provide copies of documentation when requested. 6. Dishonesty, including theft and fraudulent research results RS – You should be careful when completing expense forms, provide original receipts and keep copies for your records. Do not be tempted to forge signatures on any document and ensure that any submitted work is either your own or thoroughly referenced and attributed. 7. Irresponsible prescribing and misuse of drugs RS – Avoid prescribing for yourself or for anyone with whom you have a close personal relationship and do not use illegal substances. 8. Improper delegation RS – You must not delegate tasks to people with inadequate skills and training. Equally you should not work outside your field of competence - always take advice from a colleague if you are unsure. 9. Treatment without consent RS – Remember that consent is much more than a signature at the end of a form. You should follow Trust guidelines in terms of taking consent and only take consent if you have a good understanding of the risks and benefits of the proposed procedure. Fully document the discussions you have had including the warnings you have given. 10. Practising when a carrier of infectious disease RS – If you know that you have, or think you may have, a serious infectious disease or a condition that may affect your performance you should consult your GP and or the Trust Occupational Health Department without delay and follow their advice. If you have any queries about the issues raised in this article contact MPS on 0845 605 4000 or querydoc@mps.org.uk.

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A Place of Refuge Thom Locke reports on his time spent at the Asylum Seeker Health Clinic in Sheffield Humble Beginnings Although hidden away in a discreet side road in the centre of Sheffield, the Asylum Seeker Health Clinic is an essential focal point for the city’s estimated 1500 asylum

tuberculosis. Contrary to regular GP practices, the team of specially trained nurses see the majority of the daily appointments while the three doctors are reserved for the more complicated cases.

Unsurprisingly, the team frequently encounter the common ailments seen daily by GPs nationwide such as sore throats and back aches. But perhaps surprising to some, the most commonly seen complaint is not a tropical parasite or even tuberculosis, but disorders of mental health. These are often related to the original reasons these people The service was originally designed to fled their homeland and include post provide an introduction to the NHS and traumatic stress disorder, insomnia and offer screening and immunisation programmes for patients awaiting the ruling depression. Jenny Swann, one of the doctors at the practice, believes that these problems of their application for UK residence. However, due to the frequently protracted are invariably worsened by the stressful nature of the asylum application process nature of these cases, it has evolved into a and the difficult living conditions that her more conventional GP practice, offering daily appointments and long term care for patients have to endure. chronic illnesses such as asthma and Social Work diabetes. seekers.1 Established in 2002, following concerns that local GP practices were unable to manage the increased demand for interpreting services, the clinic currently has over 1300 registered patients.

An Uncertain Future A recent high court ruling has made NHS hospital care freely available for all failed asylum seekers.2 However, this still remains a contentious issue as the Department of Health is reported to be “considering its options on a potential appeal”.2 [This was

correct at the time of writing] For Dr Swann this area of uncertainty has frequently made it “frustratingly difficult” to effectively care for her patients and

(Source: BBC News)

contravenes a number of the General Medical Council’s ‘Duties of a Doctor’ (a The clinic is undeniably a valuable resource doctrine that all practicing UK doctors Open Doors for the health of its many visitors; however must follow).5 She also adds that “neglecting these people, who are already at it also plays a key role in addressing a Current UK law states that it is at the a greater risk of ill health, is unethical and multitude of social issues. The team have discretion of the individual GP practice will ultimately have adverse public health established good communication links with whether an asylum seeker (including those implications”. many Sheffield based organisations that can who have ‘failed’ application) may register 2 for primary healthcare. The Sheffield clinic offer free food, temporary accommodation or advice regarding the asylum application In spite of the continually changing has a policy to accept all new patients and process. In 2007 Sheffield was declared the legislation, this Sheffield clinic still manages does not enquire about their application UK’s first ‘City of Sanctuary’, an award that to provide daily unbiased support and care status. At their initial appointment new that undoubtedly helps to make the difficult recognises a “culture of hospitality for patients are triaged by one of the three 3 lives of the city’s asylum seeker population people seeking sanctuary in the UK”. nurse practitioners; this involves questioning 4 more manageable. London has also since received this award. about previous medical problems, past vaccinations and offering screening for Thom Locke is currently studying A 33 year old gentleman from Zimbabwe HIV/AIDS, hepatitis B, syphilis and International Health at UCL. He became who has been in the UK since February 2006 described the clinic as a “safe place” interested in asylum seeker health issues and “somewhere where people will listen”. after attending a presentation about the Medsin project ‘Defend Primary Already two years into his application Healthcare’. process he has no hope for a prompt decision and expressed a deep anguish at the law that prevents him from legally working To find out more: in the UK: “If I could work I could support Get involved with the ‘Defend Primary Healthmy family back home and contribute [via care Project’ at Medsin UCL – this campaign taxes] and repay the help I have received protects primary healthcare access for failed here [at the Asylum Seeker Health Clinic]”. asylum seekers. Email medsin.ucl@gmail.com (Source: BBC News) to find out more and get involved.

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Pregnant in the Land of Gold Karolina Tuomisto reflects on her trip to Ghana this summer

t’s for free. Ghana is working to increase the number of births attended by a skilled health professional and as of July, all women in the land of gold can deliver for free at any public health care facility. Until now more than half of the women gave birth alone or without a trained birth attendant for reasons of tradition, geography, long distances to health care facilities and lack of skilled health professionals.

Women lie wrapped in beautiful Ghanaian materials on the hospital beds in the labour ward. There is some moaning and snapping of fingers, but otherwise everything looks calm and peaceful. Suddenly one of the women starts slapping the wall with her hands and screams evidently in immense pain. I stop one of the passing midwives and ask about giving her something for the pain. She says she can only give her some paracetamol. How about a proper anaesthetic? The only available anaesthetist is busy in the I step into the antenatal clinic just in time to meet the first patient. operating theatres, and there have not been any anaesthesia supplies Looking at the patient’s file, I see the on the ward this whole week. revealing patient code: this woman has HIV. After examining her enlarged belly The ‘brain drain’ (emigration of health with his talented hands, the professor professionals to more developed countries), explains to her how she will need to start poverty, lack of education, illegality of medication in order to prevent her unborn abortion, and stigma are some of the major child from contracting HIV. The woman causes of disease and death of mothers in looks terrified because she has heard about Ghana. The hard working health professionals the high costs of the antiretroviral treatment who stay in the country do their best to work for HIV. Luckily however, Bill Gates against these negative forces, but sometimes subsidises most of the HIV therapy in the working environment is overwhelming. Ghana and therefore this patient will only During my stay, a few very sad events pay a very small amount per month for the occurred: the death of a medical student from drugs. The government contributes very an initially preventable disease and the suicide little. of a prominent doctor brought darkness under the eyes of the hospital staff as well as to the In the operating theatre, a bowl is filled with colour of their clothes. 18 tumours. The woman lying on the Inside the operating theatre of the delivery operating table had come to see a doctor room, a baby is out in one minute after the because she thought she was pregnant. surgeon’s knife touches the skin of the patient. Indeed she had had an enlarged stomach, The neonatal nurse looks worried and uses but because of 18 large tumours. The suction to clear the baby’s airways, without standard treatment for this is to remove the any luck. She pokes the baby and hangs it in womb but the patient refused… I ask the the air, without any luck. She gives oxygen to professor, why didn’t she want to get her the baby, and finally she smiles and so do I. womb removed? Because she hasn’t completed her family despite The little baby boy starts peeing all over the blanket and lets out a already having five children, I’m told. Another reason could be the small cry. She takes the baby to the mother and for a moment belief some people in Ghana have that if the uterus is removed, the everything in the room stops. The mother flashes an approving monthly bleeding will cease, so the blood will collect inside the smile towards the baby and the work continues. Suddenly woman and cause disease. It is sometimes difficult to explain that everything in my visual field becomes messy and I wonder whether without the uterus, there’s no blood in the first place. I’m about to faint. I feel something warm and wet on my cheek and I realise the cause of my blurred vision. It’s merely tears I shed On call in gynaecology, a very unwell girl is pushed in to the for witnessing the beauty of life. emergency room. The diagnosis of the referral says botched abortion attempt. This girl was 14 years old and had been some 20 Karolina Tuomisto is a final year medical student from the weeks pregnant. Failing to get a safe abortion, despite several University of Helsinki in Finland and went to Ghana through the attempts in her village, she had decided to carry out the abortion IFMSA Professional Exchange Programme. herself. Having had a few bottles of Guinness and a bunch of paracetamol pills, she took a wooden stick and had somehow managed to enter her cervix. And now she was dying in the To find out more Emergency Room. Visit www.ifmsa.org or contact Medsin UCL at medsin.ucl@gmail.com

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Wealthy Pharmaceutical Companies, Unhealthy World The raison d’être of pharmaceutical companies is to make profits but should they not also have a role in making the world a healthier place? Zaneta Forson tries to answer this loaded question Disengaged with reality “Many people, most of them in tropical countries of the [developing world], die of preventable, curable diseases.… Malaria, tuberculosis, [lung infections] - in 1998, these [diseases] claimed 6.1 million lives. People died because the drugs to treat those illnesses are nonexistent or are no longer effective. They died because it doesn’t pay to keep them alive”1. The stagnation in the development of drugs for diseases of developing countries stems from a lack of financial interest in medical research, not a scientific inability. The possibility exists but the market does not. Millions of people need these drugs but are unable to afford them. As a consequence, the return on research and development (R&D) is minimal for tropical disease medication and accounted for only 1% of all new drugs produced between 1975 and 19992. Wealth versus Health In the past, the protection of colonial and military interests spurred major pharmaceutical companies to action, in order to protect expatriates from developed countries3. For example, the US government invested in malaria research during the Vietnam War. However, as the Guardian explains, “When there is no pressing military or colonial imperative, the developed world loses interest in tropical diseases.”4 J. W. Smith, founder of the Institute of Economic Democracy, argues that “there is a direct conflict between the pursuit of health and the pursuit of wealth.”5 The drive for money has overshadowed the original purpose of medication resulting in the current imbalanced situation. The pursuit of health and wealth c a n o c c u r simultaneously, but that is not what is happening. Indeed some of the largest e a r n e r s i n pharmaceuticals are lifestyle drugs, such as diet pills and Viagra whilst more severe Figure 1 - www.peopleandplanet.org/.../ health issues are being put on the backburner.

The proportion of people without access to essential medicines, based on income (UN Millennium Project HIV/AIDS, Malaria, TB and Access to Essential Medicines 2005)

In theory this could allow them to redirect some funds to tropical disease drugs R&D without jeopardizing annual profit. Julian Borger wrote in the Guardian, “The combined worth of the world’s top five drug companies is twice the combined GDP [Gross Domestic Product] of all sub-Saharan Africa and their influence on the rules of world trade is many times stronger because they can bring their wealth to bear directly on the levers of western power.”6 This further highlights the potential for drug companies to guide the focus of research and policy. Importantly, the pharmaceutical industry does make some contributions to the management of diseases plaguing developing countries. Three main channels are used; donations of free drugs, selling drugs at subsidised prices and sponsorship of programs that address certain diseases7. Since 1995 Novartis and the Novartis foundation has provided, in conjunction with the World Health Organization, free multi-drug treatment for Leprosy to patients all over the world8. This has had an enormous impact, and many highly endemic countries have eliminated the disease9. A more specific example would be the African Comprehensive HIV/AIDS Partnerships (ACHAP) which has received funding in excess of $50 million as well as anti-retroviral drugs from the Merck Company Foundation to support the Botswana government’s program10.

Patents ensure that only the patent-holder can produce the drug for a certain period of time. This creates an incentive for research by ensuring that the substantial costs of R&D can be recovered in sales. It makes perfect sense until you consider that many people in developing countries would benefit from the innovation of The financial and political power of drug companies is substantial. patented drugs. Despite being essential to the workings of the

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

pharmaceutical companies, patents drive up the prices of drugs Breaking Boundaries and What’s to Come making them unattainable to many of the world’s poor11. Developing countries are slowly trying to cut the cord. The Indian pharmaceutical industry, estimated to be worth $ 4.5 billion, is Who is responsible? ‘growing at about 8 to 9 percent annually’ and is a pioneer in The basic nature of a business is to make a profit which is a duty providing affordable drugs to other developing countries in Africa to their shareholders. However these shareholders are not the only and Asia. Earlier this year the Indian government ruled in favor of stakeholders, the consumers and the communities in which they the Indian pharmaceutical industry in their battle against Novartis operate as a whole are affected. This brings in the idea of corporate that they may continue to produce generic drugs for diseases such social responsibility, which is about “how companies manage the as AIDS and Malaria at a cheaper rate . business process to produce an overall positive impact on society.”12 Engaging in activities such as donation and subsidy, In 2008 in Brazil, the government rejected the patent application especially in the current climate of global health awareness, would submitted by Gilead Sciences for an essential AIDS medication; generate positive media coverage and could be beneficial in the this was the first patent rejection of an anti-retroviral drug and it future. On the other hand, the allows the country to produce developing countries should have generic antiretroviral drugs. It responsibility for the health of will lead to wider access for the citizens despite the levels of World Health Organization corruption in some of these approved drugs for more nations. J. W. Smith argued, developing countries. “little satisfaction is to be had from watching a corrupt Hopefully in the future there will government use aid to feed its be more incentives for drug soldiers to keep the corrupt in companies to focus on neglected power.”13 Governments need to diseases. Gordon Brown is trying be more accountable and increase to encourage drug companies to funding for health programs develop HIV and malaria vaccines with the promise of However, even if a developing buying 200-300 million doses of country wants to produce its own the v ac cines wi th o ther Figure 3: http://endpovertyblog.org/files/u1/pills.jp generic (not name-branded) governments after development.20 medication, the current The guarantee of financial return pharmaceutical infrastructure and protection by patents make the would allow the drug companies to maintain a commercial interest production of drugs by developing countries substantially more whilst providing essential medication. There may be a further trend difficult. Patents and intellectual property rights prohibit anyone towards this kind of public-private partnership in the future21. from reproducing a drug or a very closely related compound. Intellectual property right (IPR) essentially means “defined rights There is a plethora of unresolved questions surrounding the role of to the exclusive exploitation of intellectual property granted by a the pharmaceutical companies in combating diseases of developing national or supra-national authority – most commonly, countries, and they are unlikely to be answered in the near future. patents…”14 Although designed to stimulate research the It will take the co-operation of several governmental and nonindependent commission on Intellectual property rights have governmental bodies, but it is possible. As developing countries shown that, “[IPR] hardly plays any role in stimulating research fight to find ways to help themselves, they need support from the on diseases particularly prevalent in developing countries”15 The wealthier nations. Drug companies are taking on more social commission also notes that IPRs are not advantageous to responsibility which is a positive initiative but more needs to be developing countries in the same way as they are to developed done. It begs the question what is the price of a life? It seems that countries16. As a result the commission reasons that the World some are worth more than others. In a world where first-world Trade Organization and others involved in the IPR process need leaders talk of globalisation and making the world one big nation, to address the effect of IPRs on the accessibility to essential there are still a lot of second-class citizens. medicine in developing countries. 17

18.

Zaneta Forson is a 3rd year medical student at UCL currently The capabilities of disease to spread across borders have been studying International Health and is extremely interested in highlighted more than once in recent history with the advancement promoting global health issues. of SARS, AIDS, and bird flu. There is a very real motivation for these nations to research diseases of developing countries. Business, To find out more: leisure travel and migration to and from developing countries have Get involved with Medsin UCL’s Universities Allied for Essential Medicines (UAEM) campaign. Visit www.uclmedsin.org/ increased greatly over recent years and reducing the level of disease uaem.htm for more information in poorer countries would benefit the high-income nations. From a financial point of view an increased market in developed countries Read “The Power of Pills: Social, Ethical and Legal Issues in Drug is an incentive for research into tropical diseases. Development, Marketing and Pricing” by Jillian Clare Cohen

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Diabetes Taking Africa By Storm The recent rise of diabetes in sub-Saharan Africa is a classic example of our ignorance about the region. Uma Mukherjee tries to raise awareness of this important issue

eorge Kimble once said “the darkest thing about Africa has always been our ignorance of it” and with regards to diabetes, this could well be true. Owing to its association with Western lifestyles, diabetes was once thought to be a rare disease in sub-Saharan Africa. Urban populations are, however, increasingly exposing this fallacy and forcing the world to re-examine and ultimately recognise that the emergence of the condition is already representing an enormous burden to health systems in the region. In 2003, 2.4% of people living in Africa were estimated to have diabetes1 and this prevalence is expected to double by 20252. Furthermore, in the region of subSaharan Africa, there are between 1 and 3 undiagnosed cases for every diagnosis3.

Diabetes Association meeting and education session Quelimane, Mozambique

Diabetes is a non-communicable disease (NCD), with two principle forms: types 1 and 2. The latter is more common within However, diabetes is not confined merely to urban settlements; sub-Saharan Africa and usually affects older (>40 years old), obese Nigerian women aged 51 and above, in a rural community near individuals. Maiduguri in the North East of the country, were found to have Sub-Saharan Africa now teeters on the brink of a diabetes disaster, significantly high fasting glucose blood samples 10. This will contribute to obesity which is concordant with the high prevalence with the World Health Organisation (WHO) predicting that of diabetes in Nigeria (2.2%)11. 75% of the world’s diabetics will live in developing countries by 20254. How has this staggering explosion arisen yet remained largely undetected by the global community and more importantly, Changing dietary patterns, particularly towards Western-orientated food, which is high in saturated fats and sugars, have marginalized is sub-Saharan Africa ready to face this epidemic? traditional high-fibre diets and are further fuelling the looming overweight crisis: half of all South African women and a third of The WHO predicts that sub-Saharan Africa has already lost US all men are overweight 12. Globalisation of food markets is $41.76 billion through diabetes5. This figure includes direct costs, inextricably linked with increasing sedentary lifestyles and for example medication, and indirect costs, such as economic marketing of processed foods. Ironically, the worldwide clamour productivity losses since type 2 diabetes largely affects for increased global trade with sub-Saharan Africa is force-feeding economically active populations (18-65 year olds). This brings yet a generation into contracting diabetes. another financial hardship to a continent that is already afflicted with debt repayments, political and social disruptions6 as well as a In some areas, the cultural significance of overweight women as symbols of prosperity, happiness, attractiveness and good health 13, plethora of infectious epidemics. may render obesity and diabetes issues difficult to resolve. Indeed, weight loss and wasting are symptoms of the often stigmatised Sub-Saharan Africa now teeters on AIDS, and this is a further obstacle to raising awareness of diabetes in sub-Saharan Africa

“

the brink of a diabetes disaster”

Critically, some Africans do not believe in Western medicine 14, and will instead consult traditional healers, who may be unwilling to refer patients to doctors 15. Spiritual causal theories of diabetes, The Effect of Globalisation, Urbanisation and Social Stigma such as sorcery and witchcraft, are still found, especially in rural Urbanisation is a growing trend in sub-Saharan Africa, with 70% communities 16. While these may not harm the individual, any delay in seeking proper care could hasten medical complications, of Africans estimated to reside within cities by 20257. This will foster continual increases in obesity due to the differences between including blindness and limb amputations and reduce life expectancy still further. urban and rural lifestyles. Whilst rural populations remain dependent on walking and intensive agriculture for their Inadequate Education, Improper Healthcare livelihood8, obesity is at least four times higher in urban areas9, as lifestyles are often more sedentary amongst urban populations. The scarcity of skilled health workers and proper training

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

centres makes it difficult to adequately educate diabetics. For disease progression. example, in December 2006 there were only two diabetes specialists in Zambia 17. Effective diabetes management is So, where do we go from here? endangered both by sub-optimal treatment referral 18 and dosing complications, the latter due to little standardisation of the insulin In order to address the issue of diabetes in sub-Saharan Africa it is important that responsibility for intervention is syringes used to treat type 1 diabetes 19. not assumed on a solely individual level. Instead, there must be a collaboration of forces including Tackling the contributory causes early on is international governments, national policy makers, key to prevention; the ‘Barker hypothesis’ non–government organisations, pharmaceutical proposes that the origins of some chronic companies, health centres and local communities28. conditions are determined early in International involvement must be both long-term childhood. This is pertinent, since and sustainable; sub-Saharan Africa must not be malnutrition, common in developing left to witness this alone. countries, can cause stunted growth, which in turn provides a 2-7% risk for being overweight 20.

Blood glucose testing at World Diabetes Day 2007 in Maputo, Mozambique

However, political measures that may improve quality of life in some nations may have untold consequences in others. The 2004 WHO proposal Inexpensive provisions of insulin, sterile syringes and other to tackle world obesity by limiting daily sugar intake could harm medications cannot be guaranteed by the chronically under-funded the economies of small sugar producing countries, for example in national health services and obtaining these supplies from the Swaziland, where sugar trading is considered instrumental in lifting private health sector is too expensive. Sub-Saharan African the population out of poverty29. countries spend less than 10% of their public health budgets on Efforts at the level of prevention, monitoring and control of the prevention and treatment of NCDs 21, which in 1990 already diabetes should be applied with the same vigour and intensity as constituted 14% of the total sub-Saharan African disease burden22. elsewhere in the world. Mass screening programmes are imperative, focusing not only on high-risk individuals, but where possible, on More emphasis is instead placed on communicable, infectious the population as a whole30. Increasing awareness will hopefully diseases, like malaria and tuberculosis 23. ensure that chronic diseases are prioritised on the global health agenda. This will go a long way to reorganising health systems in Increasing both national and international awareness is vital. sub-Saharan Africa so that chronic care is given as Crucially, it was anticipated that 2007 would much importance as acute, infectious diseases. see just as many deaths worldwide from diabetes as from AIDS24, although the This challenge is not insurmountable and distribution is unequal in different parts of the evidence suggests that despite the inherent world. In fact, increasing access to antiretroviral traditions, some populations are willing to reduce drugs as a treatment for AIDS leads to a 4 fold their body size for health and social reasons. The associated increase in diabetes risk 25, because difficulty lies in spreading healthy eating habits to AIDS sufferers are starting to live long enough the large populations of malnourished people in subto contract diabetes later on in life. Saharan Africa, for the majority of whom the lure of a balanced diet remains a distant prospect. The World Bank also plays its part in the subEnormous sensitivity is thus required and this must Saharan African burden of diabetes. Of its US be balanced against the realisation that to tackle this $4.25 billion provision for health programmes global issue, we must act decisively and quickly to worldwide, only 2.5% was used to fund the prevent the burden of diabetes in sub-Saharan prevention of NCD’s and all of it went to Education session on diabetes in Africa from expanding further. Eastern European projects 26, while even Maputo, Mozambique prominent charities like the Bill and Melinda Uma Mukherjee is a 3rd year (BSc) UCL student in Gates Foundation have no focus on NCDs 27. medicine. She is interested in health inequalities Lack of research and publication in peer-reviews within the region within African populations. has contributed to the paucity in international attention on With special thanks to International Insulin Foundation (IIF) for diabetes in sub-Saharan Africa. permission to reproduce all photographs. Educating diabetics and non-diabetics about symptoms and the importance of regular check-ups is essential but particularly problematic in countries with low literacy rates. Following diagnosis and commencement of proper treatment, diabetics must self-manage their condition by taking their medication as instructed, adhering to certain lifestyle changes, and dealing with the accompanying psychological burdens. These all impact the success of implemented strategies and determine the nature of

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To find out more: Read ‘Perceptions of Overweight African Women About Acceptable Body Size of Women and Children’ in Curationis 1999; 22: 27–31 Visit www.access2insulin.org/factsheet.pdf Visit www.scienceinafrica.co.za/2006/december/diabetes.htm

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

The Globalisation of Medical Research As medical research goes international, the ethics have been left behind. Alexandra Müller illustrates this point by analysing a controversial research trial carried out in Nigeria

n 1996, Nigeria was ravaged by one of the worst meningitis epidemics in its history. The health care system was struggling with the number of patients, mostly children, who needed medical treatment. The multinational pharmaceutical company Pfizer offered help – and sent medical staff to the region of Kano. The events that followed led to a high profile court case, with Pfizer being sued for over US$9 billion in

but instead only a third of the dose proven efficient; and that letters of permission from the Nigerian authorities were fabricated only after the study had ended2. Pfizer rejects the accusations of having conducted an unauthorized and unethical clinical trial3. The need for health care research in the developing world Article 25 of the Universal Declaration of

“Nigerian families filed a lawsuit against Pfizer, alleging that Pfizer violated international law by not obtaining informed consent.” compensation. What happened? And how was this symptomatic for the current state of international medical research? The case of Pfizer in Nigeria

Human Rights recognises that “everyone has the right to a standard of living adequate for ... health and well-being of himself and his family”4. The purpose of medical research is to increase knowledge of causes, symptoms and treatment of diseases and constitutes an integral part of health

destined to work on what constitutes 90% of the world’s health problems6. The ethical dilemma Like in the case of Pfizer, a US company conducting a clinical trial in Nigeria, research studies are often initiated and designed by foreign research bodies in their own country and brought to developing countries for clinical trials. The circumstances of extreme inequities and poverty in which the research participants live are often disregarded7. Research in the medical field has increased more than 16fold over the past 15 years, yet there is no central international regulatory body to oversee the complex ethical issues resulting from research that spans more than one country8. The ethical framework of medical research needs to be adjusted to the new international realities. There are four key guidelines to ethical conduct in research, developed from various documents such as the Helsinki Declaration9 and the Nuffield report on Bioethics10. These were all disregarded in some way in the Pfizer case.

Pfizer, when entering the meningitis epidemic in Nigeria, wanted to test the oral administration of the antibiotic trovafloxacin, a meningitis drug not approved for the treatment of children. According to parents whose children were treated, they were not informed about the clinical trial, nor were they given information about the drug and its possible side effects or risks. Free and informed consent The Pfizer physicians worked alongside the staff of Médecins The ethical guidelines are Sans Frontières (Doctors unmistakable: “An Without Borders) and offered intervention in the health field help where there otherwise may only be carried out after would have been none. They the person concerned has given free and informed consent.”11 enrolled 100 children who were Trial participants waiting in line (Source: www.cache.daylife.com) In Kano, parents claimed that to be treated with trovafloxacin care. Over the past three decades, it has they had not been informed that their child and an equal number who were to be treated with ceftriaxone, the gold standard become evident that the distribution, nature, was receiving experimental treatment in a clinical trial and that Pfizer had omitted treatment at the time. Of the 200 children and burden of disease are different in developing countries and the global North5. information about the side effects of enrolled in the trial, 11 died – 6 of them in Developing countries have fundamentally trovafloxacin1. This violates the right to the control arm1. In 2001, thirty Nigerian different economic opportunities, information. Furthermore ones freedom of infrastructures and cultures. Research families filed a lawsuit against Pfizer, choice is compromised when the alternative should therefore be conducted at a local alleging that Pfizer violated international to consenting to the trial is to not receive law by not obtaining informed consent. The level to recognising these specific challenges any treatment at all, especially in the midst lawsuit also alleges that the control group’s and their implications for health. Yet, only of an epidemic. Pfizer claims to have treatment was not the gold standard of care 10% of the world’s research resources are obtained consent in verbal form, as

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine most parents were illiterate, but there were no consent forms to be found. Low literacy has to be taken into account when informing potential participants about the risks and benefits of a trial, and alternative, regulated procedures for gaining consent must be followed. The standard of care Standard of care describes the quality of medical treatment that participants receive in a clinical trial. The Helsinki Declaration states that “…the benefits, risk, burden and effectiveness of a new method should be tested against those of the best current […] methods”12. The lawsuit against Pfizer claimed that the treatment dose for children in the control arm was lower than recommended, thus not the best current treatment available13.

access to treatment regimens among those internationally recognized as optimal”10. How this standard should be maintained by financially restricted public health systems after the end of trials remains an unanswered question. The need for ethical review

“Developing countries often lack experienced staff and qualified institutions to perform ethical reviews ”

benefits include access to the investigated drug or medical intervention after the end of the trial, but can also entail long-term structural improvements to components of the health care service. A framework for sharing these benefits is, however, not clearly defined, and the responsibility is mostly placed upon the researcher 18,19. This illustrates the lack of guidance that is common to all ethical frameworks. There exists an unanswered question of who should be held responsible and by whom.

When researchers operate in international environments including resource-limited regions, national bodies often lack the To address issues of informed consent and capacity and the jurisdiction to regulate and control these research activities. The case of standard of care, it is imperative that each Pfizer’s trovafloxacin study highlights that trial undergoes review at independent ethical standards and limitations have Institutional Review Boards (IRBs). Developing countries often lack experienced apparently been overlooked in this trial – if not openly violated. This happened despite staff and qualified institutions to perform the existence of the international ethical As another example, in 1997, the World ethical reviews, and UNAIDS therefore framework as presented in the guidelines Health Organization (WHO) and the recommends that trials should only be above. It re-emphasizes the need for conducted “…in countries independent ethical review boards with and communities that have sufficient capacities of enforcement, as well appropriate capacity to as the need for involvement of the local conduct independent and community in all steps of the process to competent […] ethical ensure that their interests and concerns are review”15. Ethical review should be conducted both in recognized. There is also a need for the medical and legal community and the public the country of origin of the to critically monitor the practice of researcher, as well as in the international researchers, while bearing in country where the trial is to mind what holds the highest value: the take place. UNAIDS rights of the trial participant. The claims in recommends that a special emphasis should be placed on the Pfizer case have been dismissed in the Source: www.shutterstock.com US, and the case is now to be put on trial in the involvement of the local AIDS Clinical Trials Group (ACTG) community in “…the design, development, Nigeria – the same country where Pfizer conducted its questionable trial with no initiated a clinical trial at 15 sites in various implementation and distribution of intervention from the authorities. results”16. In the Pfizer case, the company countries in Africa and South-East Asia. This trial sparked an ethical debate over the later admitted that the local approval might Alexandra Müller is a medical student in use of a placebo as a control to evaluate the not have been properly documented – one her final year at Göttingen University in of the Nigerian physicians involved stated efficacy of treatment for mother-to-child Germany and has been conducting research transmission of HIV – in a situation when that IRB approval was obtained only after on HIV treatment adherence at the the trial, and that the letter of approval was the clinical gold standard in developed University of Cape Town, South Africa for backdated accordingly1. Among these countries was an antiretroviral agent with the past 3 years. proven efficacy14. Researchers in favour of violations of ethical review, the community the use of placebo argued that this of Kano had not been consulted in the corresponded to the local gold standard of design of the trial or its protocol. care (there was no treatment available), To find out more: whereas others argued that a universal gold The benefit of research Read “The Constant Gardener” by John standard of care should be applied, based on Le Carre (see review of the film on page the global treatment options. The Joint The local community also plays a key role 28) United Nations Program on HIV/AIDS with respect to the benefits of research. (UNAIDS) and the WHO have adopted Medical research is only justified if the Read “The Body Hunters: Testing New this viewpoint and now require that population in which it is carried out stands Drugs on the World's Poorest Patients” “participants […] should be provided to benefit from the results17. Possible by Sonia Shah

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Female Genital Mutilation: To Cut or Not to Cut? Female Genital Mutilation is considered a human rights violation by the United Nations (UN) yet it is still practised by many women around the world. Paladia Ziss attempts to explore the culture behind the practice

ccording to the World Health Organisation, 100 to 400 million girls and women in 28 countries in Africa the Middle East and Asia have undergone genital cutting as a child1,2. Every year, another 3 million girls are subjected to one of three types of the practice. Depending on the area and culture, the cutting ranges from partial removal, where a small incision is made in the clitoris, to labiadectomy, the complete removal of female external genitalia, by cutting the labia and stitching the vagina closed with a small opening for urine and menstruation. The UN and attached organisations have listed this practice as a human rights violation and oppose all forms of female genital cutting. They emphasise this by referring to it as Female Genital Mutilation (FGM).2

Fidelity and Femininity FGM is considered a remnant of heavy gender inequality. In countries with widespread practise of FGM, cutting of the clitoris is thought to limit the female sexual desire and thus ensure premarital fidelity. In some cultures, the female genitalia are traditionally viewed as ‘manly’ and so have to be removed in order to initiate femininity and improve marital prospects. Furthermore, similar to male circumcision, the practice serves as a rite of passage into womanhood3. The medical equipment used for the procedure often consists of glass or normal kitchen knives, and frequently without anaesthesia or sterilisation. Besides the immediate risk of death, heavy bleeding or inflammation of poorly closed wounds, medical studies demonstrate that FGM (especially labiodectomy) increases the probability of urinary infections and childbirth complications in the long term4. Adverse effects related to sexual desire and pleasure are also reported5. Scientists Afifi and von Bothmer claim to have found an association between FGM and the use of violence against one’s own child. The authors believe this to be due to the psychosexual trauma suffered from FGM6. International campaigning and the UN recognition of FGM as a human rights violation has encouraged many countries to officially

“FGM is considered a remnant of heavy gender inequality” oppose the practice. The country with the highest prevalence of FGM, Egypt, imposed a complete ban in 2007 after a girl died from an overdose of anaesthetics7. Education about the surgical risks has resulted in an increased number of women taking their daughters to a doctor or a trained nurse to carry out the ritual, which has helped reduce the immediate risks for the girl. However, no clear trend of a decline in the practise of FGM could be found.2 CenturiesCenturies-Old Tradition or Criminal Act

Source: www. Afrol.com

Why have international campaigners had such difficulties in ending the practise? One problem is that it is often women themselves who uphold the practise of FGM. Social scientists and the

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Source: www.mywokenya.org UN acknowledge the fact that although many mothers claim to oppose female genital cutting in interviews, they still insist on having their daughters subjected to the practise.2,3 The underlying motivation for many of these mothers is the fear that, without FGM, they will not be able to marry their daughters off. They do not want to buck with a centuries-old tradition Another problem might be the severity with which anti-FGM activists label female genital cutting as a crime aimed to abolish female sexual pleasure. The Sierra Leonean anthropologist Fuambai Ahmadu, who was educated in the United States and who is circumcised herself, claims that the argument about reduced sexual pleasure is a construction of anti-FGM campaigners and could not be proven by experience and interviews with both married women and sex-workers8. Furthermore, she questions why FGM as practised by millions of women in Africa is less tolerable than voluntary genital modification of women not happy with the looks of their genitals in the USA and other Western countries.

example, fled from an arranged marriage from her Sudanese home at the age of 13, became a model in France and then wrote her autobiography, ‘Desert Flower’, in which she describes how her experience of FGM has made her suffer. Today she is a famous author and anti-FGM activist acclaimed in the Western world and in her home country of Sudan. It is difficult to end the practice of FGM. Although it is recognized as a human rights violation and banned by many governments and its medical consequences widely acknowledged, women and the communities they belong to refuse to end the practise owing to several deep-rooted reasons. It is seen as a rite of passage and a prerequisite for successful marriage. International actors sometimes tend to over-criminalise the practise. It is important to differentiate between extreme cases, like labiodectomy, and cases with less severity, such as clitodectomy. To better understand the reasons why the practice is so difficult to abolish, it is important to promote an open discussion amongst women to determine if they want to continue the practise or not. A general empowerment of women is needed so that they can take on an active role in the discussions about FGM and not be patronised by either their ancestors or dogmatic activists.

“Women who are courageous enough to tell their stories are celebrated as heroines”

Model Behaviour It is freedom of choice that distinguishes both practices. A young girl of five years of age is simply not in the position to reject the surgery; and many women who are not happy with the continuation of the practise long for their voices to be heard. Women who are courageous enough to tell their stories are celebrated as heroines. Waris Dirie, for

Paladia Ziss is a 2nd year Human Sciences student at UCL and her interest in FGM developed during an internship with the German Development Bank in Sierra Leone

To find out more Read “Desert Flower” by Waris Dirie Read the book “Cutting the rose: female genital mutilation: the practice and its prevention” by Efua Dorkenoo, Read the book “Female genital cutting: cultural conflict in the global community” by Elizabeth Heger Boyle Anti-FGM activist Waris Dirie

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Reviews Chasing the Flame: Sergio Vieira de Mello and the Fight to Save the World by Samantha Power Published by Allen Lane, £17.50 from Amazon.co.uk Power mercifully skates over the more prosaic details of his early family life (as well as his slightly cringe-inducing phase as a Parisian student revolutionary) to focus on the moral dilemmas his work forces him into. The author looks on aghast as Vieira de Mello wines and dines senior figures of the Khmer Rouge in order to negotiate the safe passage of Cambodian refugees, or cosies up to Milosevic and Karadzic while attempting to break the siege of Sarajevo. In her new biography, Samantha Power Indeed, it soon emerges that the book's real discusses the life and death of the former strength is the way we are expertly taken Brazilian United Nations aid worker Sergio behind the scenes of some of the messiest Vieira de Mello. She charts a career spent in human catastrophes of the last 30 years. and around the world’s violent hotspots, as Power flexes her muscles as a professor of Vieira de Mello applies his talents and political science to deliver a short history of idealism to genocide in the Congo, political a generation's worth of civil and ethnic crises in East Timor and just about strife, and global society's botched attempts everywhere in between. to find solutions.

We are still given a compelling portrait of Vieira de Mello himself, who in his moments of weakness deeply feels the impotence and frustration that must accompany anyone desperate to make a difference; in fact, almost all of his missions end up as high profile failures. And by the end, any glimmer of optimism is all but extinguished as Power recounts his slow and depressingly preventable death at the hands of Iraqi insurgents in 2003. Nevertheless, the book offers an incisive and occasionally inspirational look at our potential to alleviate human suffering, and should probably be mandatory reading for wouldbe professional do-gooders everywhere. By Kene Agwu

The Constant Gardener

Sicko

Directed by Fernando Mereilles

Directed by Michael Moore

Few directors have attempted to tackle as controversial or grave an issue as Fernando Meirelles does in The Constant Gardener. Set in a province of Kenya, the film focuses on the notorious, unethical, and sometimes brutal actions undertaken by pharmaceutical companies in the third world. The story centres around a Western diplomat who, whilst searching for those responsible for his wife’s murder, uncovers dangerous truths surrounding the world of medical drug trials. Through the eyes of Justin Quayle, played by Ralph Fiennes, the audience witness the underhand tactics companies will use to get their drug on the market. Threatened with the loss of the basic healthcare available to them, the poorest people in the

poorest nations are bullied into taking part in trials, in which some of them will die. We have all had to take medication at some point in our lives, but few of us, I believe, have ever given much thought to the process though which the drugs we take appear on our shelves; perhaps The Constant Gardener is the turning point. It is important to note that this is a sensationalist film, which is based on fiction, though it should be credited for tackling a very real and contentious issue. With many heart-wrenching moments coupled with shocking revelations, this film is sure to induce deep thought into the relatively unreported world of medical drug trials. By Lucy Reeve

Well known director and producer of Fahrenheit 9/11, Michael Moore, sets out to find explanations as to why, despite being the wealthiest nation on Earth, America’s health is one of the worst among all developed countries. On his quest to find explanations, Moore looks into the healthcare systems of other countries within the developed world and uncovers evidence that suggests America’s health system is not the most effective. Throughout filming, Moore meets Americans from varying backgrounds who are all, for a multitude of reasons, struggling to fund the cost of their healthcare. After listening to their stories he decides to take a group of them to find

some better healthcare, in the most unexpected of places. By including some very moving accounts of personal struggles with healthcare, Moore succeeds in revealing the true nature of the insurance companies that appear to control America’s healthcare system. The very surprising revelations and statistics make this documentary style film well worth watching. By Lucy Reeve

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

The Invisible Cure; Africa, the West and the Fight Against AIDS by Helen Epstein Published by Penguin Books Ltd, £6.99 from Amazon.co.uk or available from UCL library The Invisible Cure is a balanced and well- book accessible and allows the reader to humanise the statistics and identify with the researched book on both the past and current status of the HIV/AIDS situation problem. in Africa. From her writing, Dr. Helen Epstein’s dedication and passion for Africa becomes clear, and armed with her common sense and experience, she has produced a fantastic portrayal of the continent’s most recent pandemic and gives a promising example of fighting AIDS effectively. Helen Epstein begins the book autobiographically, explaining how she became interested in researching an HIV vaccine and how this interest led her to her first encounter with Africa and a career change towards public health and journalism. This book is a summary of a decades worth of reporting in various publications including The New York Times Magazine. Her anecdotal and sensible approach to the subject makes the

The book is presented in four parts. The first section explains why HIV rates in Africa are so high. The second talks about

how South Africa’s government, under President Thabo Mbeki, began to doubt whether the HIV virus actually caused AIDS, which led to mass confusion and a public health disaster. The most powerful chapters though are in the third section, which explains the differences in approach in dealing with HIV between South Africa and Uganda, and why Uganda has been more successful in fighting the spread of HIV. The success in Uganda was due to the realisation that HIV/AIDS was everyone’s problem, which allowed open discussions about the subject. This reduced the social stigma and led to a social movement. This is what Dr Epstein calls The Invisible Cure – drugs alone will not save Africa from HIV/AIDS, the social taboo which surrounds HIV/AIDS will also have to be eradicated. By Elena Ferran

The Truth About Markets by John Kay and The ABC's of Political Economy: A Modern Approach by Robin Hahnel The Truth About Markets is published by Penguin Books Ltd, £7.25 from Amazon.co.uk Getting to grips with economics is a crucial, but difficult step in understanding global health. There is a near-universal trend; wealth equals health, poverty begets disease. Hahnel and Kay, both Professors of economics, have produced two accessible and popular books, tapping into the global demand to understand capitalism, the economic system of our times. John Kay’s The Truth About Markets is an excellent introduction to understanding ‘the market’. Kay explores how the market distributes goods, sets prices and delivers efficiently, without any central control room. He also lucidly explains the mysterious economic function played by our now-infamous credit markets. The path is lit by Kay’s sharp wit, interesting anecdotes and enthusiastic myth-busting. His central message is that the market is unique because it allows hundreds of competing trial-and-error attempts to improve the world, and the market selects the fittest (most efficient and profitable)

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adaptation, almost like evolution. He calls participatory economic system for the this “disciplined pluralism”. future. The two books complement each other well, with Kay’s an easier (albeit roseHahnel’s The ABC's of Political Economy tinted) introduction, whilst Hahnel dissects takes a much more critical view of the the market more deeply, revealing its darker market. It starts with exploring what we side. want from our economy, and then reviews the market’s ability to meet our needs. This By Peter Baker is crucial for global health, because if we can identify what health needs we desire, then political economy can help us choose the right economic system to achieve these needs. The ABC's of Political Economy is a much more rigorous look at the market and economic theory, and is harder going. It is, however, definitely worth it. Hahnel makes you leave each section with a much clearer and more precise understanding of the pros and cons of market forces than Kay’s anecdotal style. He coherently navigates issues such as why pollution is such an inherent problem for the market, how to make the market work for us, and even outlines proposals for a democratic and

October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

What’s Going on... October London Film Festival Until Thursday 30th Various Times BFI, Southbank Showcasing the best new films from around the world. Including “Beirut Open City” and “Eye of the Sun”. Visit www.bfi.org.uk/lff for more information and to book tickets

Time to Slaughter Some Sacred Cows? Confronting Failure in the War on HIV/AIDS Thursday 6th November 2008 18:30 - 20:00 Old Theatre, Old Building, LSE Dr. Elizabeth Pisani gives a controversial insider's account into the global failures in responding to the HIV/AIDS epidemic The Northern Utopia: What is Distinctive about the Nordic Countries? Tuesday 11th 13:00 – 14:00

Medsin UCL Campaign Series Tuesday 28th Venue TBC 19:00 - 20:00

This lecture explores why the Nordic countries rank so highly in indicators of economic prosperity, social solidarity and quality of life

This session will teach you the skills required for campaigning and introduce you to the various campaigns that Medsin UCL are running this year. If you want to make a change in the world then this is the event to attend!

The UCLUCL-Lancet Lecture Monday 24th 17:30 – 19:30 Kennedy Lecture Theatre, Institute of Child Health

November Medsin UCL Global Health Series Tuesday 18th 19:00 – 20:00

Venue TBC This talk will form part of our everever-popular Global Health Series. The speaker has not yet been confirmed but is sure to be a big name in global health. Visit www.uclmedsin.org for more information UCL Climate Interactions 2008 Wednesday 5th 13:00 – 17:30 Anatomy Building JZ Young Lecture Theatre

Jeremy Bentham Room, UCL

This year’s Lancet Lecture given by Professor Kazatchkine, director of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

December World AIDS Day Event Monday 1st All day UCL There will fundraising, campaigning and a social all run by the Medsin UCL Stop AIDS campaign team! Check out www.uclmedsin.org for more information Ethical Christmas Fair Thursday 18th

A discussion of the future impact of climate change and what we 16:00 – 20:30 can do about it. There will be four halfhalf-hour presentations fol- Canning House lowed by a discussion and wine reception. Visit www.ucl.ac.uk/ globalglobal-health for more information Buy your Christmas presents the ethical way! Products include beautiful handmade Ecuadorian Christmas cards. Visit www.canninghouse.com/content/events for more information

Medsin UCL sends out weekly newsletters to inform students of the latest global health events. To join our mailing list please visit www.uclmedsin.org All events are free unless otherwise stated. Medsin UCL events are in purple 30

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Scope of horror

By Natasha Lyons

Aries Watch out for your (anterior) horns Aries, because this month the West Nile Virus is on the rampage and it’s coming for your spinal cord. Milder symptoms include nausea, excessive sweating and diarrhoea, so if you’re in a relationship, be prepared for it to take a mighty battering...enjoy!

Taurus There’s a Bull’s eye in store for you this month Taurus, but not the kind that makes ageing, balding, sweaty men charge round a pub as if they’ve actually achieved something. You’re all set for a juicy tick bite that looks just like the centre of a darts board - see red and it could mean it’s Lyme’s disease.

Gemini Cancer You’ve got a secret, Good health and a Gemini and it’s long life awaits you. buried so deep that you don’t even know what it is… ‘Dissociative Identity Disorder’ allows one person to adopt two or more distinct personalities with total amnesia for these other identities. So not only do you get to live life to the full – you get to do so several times over… aren’t you special!

Libra My goodness Libra, how much more weight can that zodiac take? The scales are tipping in favour of your lard rather than your luck this month, so why not swap sweets for spinach and measure out some stable selfrestraint?

Scorpio Prepare to be astounded Scorpio – your kind may actually have a purpose. Though the ‘back-stabbing vermin of the desert’ image may take some time to dissipate, it has been discovered that scorpion’s venom could cure cystic fibrosis. Go and find someone you dislike and give them a good stinging – you deserve it!

Sagittarius Everyone knows that a Westernized human with a bow and arrow is about as lethal as a kitten, so why must you insist on parading round with one like some tribal James Bond, Sagittarius? Go back to your day job, before you lose an eye… your outlook may be bleak Sagittarius, but make sure you at least get to see it…

Capricorn Watch out Capricorn, because this month the meddlesome Beard’s disease is out to sap your sprightly powers. Causing chronic fatigue and nervous exhaustion, you’ll be stuck in a pen unless you can keep that bristly face -tail in check.

Leo After all those years of thinking that it was a thorn, this month Leo it’s time

Virgo Ah Virgo, the arch denialist. It’s time to settle down and accept that yes, it is Nesseiria Gonorrhoea . That suggestively winking eye is merely conjunctivitis and be sure to warn your admirers to stay well clear of your ‘flowing’ yellow locks. Ideally, just sit and look pretty… if you can.

Aquarius Why Aquarius, why? Sure, millions of people ‘bear’ water pots for hundreds of miles a day, but this tends to be a survival necessity, rather than a life choice. Carry on this way and you’ll end up with the aesthetic appeal of road-kill, with varicose veins that would scare-off the ‘Incredible Hulk’. It’s time to kick those buckets Aquarius…hard.

Pisces Has something just died? No, it’s just Pisces, sporting this month’s most pungent affliction – ‘fish odour syndrome’. Resulting from an inability to breakdown the fishy smelling trimethylamine, this disease does exactly what it says on the tin. So bump up that perfume collection and don yourself some friends without a sense of smell, if you ever want to leave those waters of solitude.

In praise of the present: For those of you who would prefer a ‘fleshier’ alternative to anti-septic cream, try the ancient Egyptian approach. Animal parts, ox spleen, pig’s brain and tortoise gall were used to soothe rebellious skin, as it was believed that these creature-bits had healing properties…tasty

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October 2008 - Issue 1

Medsin UCL’s Global Health Magazine

Brand New Global Health Magazine at UCL Do like to read or write about global health issues? Are you looking to gain journalistic experience and boost your CV? Then get involved with the Global Health Magazine at UCL. This is a brand new project for this year and we are currently looking for:

Editors Writers

Proofreaders Designers Photographers

No previous experience is required; all that we ask is that you have a passion for global health. All students are welcome including nonnon-medical students! So, to get involved or for more information please contact: medsinmagazine@gmail.com. medsinmagazine@gmail.com.

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medsin.ucl@googlemail.com

Look out for the second issue of the magazine to be released in December The first issue is now available for download on our website: www.uclmedsin.org

Medsin UCL is a society dedicated to tackling global health issues from around the globe, and Perspectives Magazine is just one of the many things that we do. We run Campaigns on a whole range of issues, from Malaria and HIV/AIDS, to Climate Change and Water & Hygiene. We work everywhere from the street corner with a petition, to the Houses of Parliament with our MPs—its your choice! In our Projects you’ll get to actively work with the community, from as near as Inner City London to as far afield as Ghana, and on health issues from sex education to bone marrow registry. In the end, what you do is completely up to you. Why not explore Global Health with Medsin UCL? You never know where it’ll take you! Take a closer look at Medsin UCL and sign up to our newsletter at www.uclmedsin.org, and email us, even just to say hello, at medsin.ucl@gmail.com.

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