Issue 2 - UCL Medsin Perspectives Magazine by Medsin UCL

December 2008 - Issue 2

Medsin UCL’s Global Health Magazine

December 2008—Issue 2

Perspectives

UCLU Medsin RUMS Society’s Global Health Magazine

The War on Tobacco ● The Organ Trade ● Focus on NGO’s Gender inequality in AIDS● Obama Debate http://www.uclmedsin.org

1 Published on behalf of UCLU Medsin RUMS by Davina Patel

December 2008 - Issue 2

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Medsin UCL’s Global Health Magazine

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

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December 2008 - Issue 2

Medsin UCL’s Global Health Magazine

Meet the Team

Contents »

Current Affairs

Letters

The Big Debate

The War on Tobacco

Putting a price on organs

Mixed Methods: producing global citizenship and knowledge in local places

Cover Photo Kirsty Oswald

Focus on NGOs

A traditional approach to HIV/AIDS

Interview

Politics and Healthcare

Section Writers Elena Ferran, Lucy Reeve, Michael Malley, Natalie Barry, Natasha Lyons, Ragulan Ravirajan, Zaneta Forson, Neal Russell, Maria Bartkiewicz, Hannah McCarthy, Melissa Chiu, Alisha Allana

Tribal Medicine

As easy as ABC?

Skip UCL

International Aid

Reviews

Visual Perspectives

Calendar

Organ frenzy

Core Editors Vishaal Virani, Katharine Langford, Katie Birley, Joyce Browne. Katherine Law, Rachel Scott Design Team Ruth Batham, Saameendra Das, Lucy Reeve, Karina Pall, Elena Ferran, Clare Parsons

Copy-Editors Aadarsh Shah, Anna Wight, Charlotte Lightfoot, Emily Savell, Karina Pall, Kate McAllister, Nikhil Patel, Nina Grayson, Rachael Getzels, Shagufta Fayyaz, Jonathan Cheah Webmaster Joel Cunningham 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 second issue of Perspectives, Medsin UCL’s Global Health Magazine. Since the first issue was released in October, Perspectives has really established itself at UCL, exemplified by the recent features on the UCL website. One of the most important aims of the magazine, and of Medsin UCL in general, is to educate and raise awareness of global health issues amongst students. Reflecting on the popularity of the Medsin National Conference in October and this magazine, I sense a great demand for global health education at UCL. The informal opportunities that Medsin UCL provides, through Perspectives and the fortnightly Global Health Series, are extremely valuable. However, the importance of a formal global health education structure at UCL cannot be understated. UCL offers many course units in Global Health and Development, the International Health Intercalated BSc and Masters programmes; I encourage students to take advantage of these opportunities. In addition, we at Medsin feel that there is real scope for expanding the availability of global health education at UCL. To that end, Medsin UCL plan to compile various proposals to be put to UCL academics. The aim is to increase global health education in the medical school curriculum, to increase the availability of course units in global health for non-medical students, and to promote multidisciplinary staff-student interactions around common topics in global health. For more information or to get involved with these proposals, please email medsin.ucl@gmail.com. We would love to hear from you. And finally, Medsin UCL would like to wish you a very merry Christmas. To find out how to make this Christmas an ethical one please see page 33. Vishaal Virani

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Current Affairs

December 2008 - Issue 2

By Michael Malley and Ragulan Ravirajan

Copper load of this! You’ve heard of good copper, bad copper. Well it turns out that copper alloys may be very good indeed – at fighting infection that is – and its uses may extend just a little closer to home than you might be expecting... Copper has been used as a barrier to fight infectious agents since ancient times (the Egyptians stored their water in copper jars to keep it pure) and now appears to be having a renaissance. Unlikely as it may seem, bacteria are killed when they come into contact with copper; backed up by a U.S. study showing solid copper alloys to be 99.9% effective at killing five common hospital-based pathogens including MRSA1. A clinical study is now underway in South Carolina to assess whether copper can be used to prevent hospital-acquired infections when placed at key sites known to harbour the bugs (such as bed rails, computer keyboards and visitor chairs). It is thought that copper may also have other public health applications, for example for use on public transport systems where copper may be strategically placed to kill the bugs your neighbour sneezes out in the morning rush hour, but also in water reservoirs. The relatively inexpensive metal could be used to safeguard clean water supplies across the world by preventing the contamination of water in freshly dug wells and ensuring the safe transport of clean water. The uses of copper may not end there. Can you, for instance, imagine wearing socks and even underwear made with copper threads to prevent fungal infection? Didn’t think so. Codelco on the other hand, Chile’s largest copper company, envisages just that. Perhaps the Milan catwalks should prepare themselves for a revolution. Time will tell how useful copper might be in fighting infection, but whether it be in your local hospital or in the next range of Calvin Klein remains to be seen.

The Lessons Learnt from Hurricane Katrina Hurricane Gustav was the seventh tropical cyclone of the 2008 Atlantic Hurricane season. It severely affected Haiti, the Dominican Republic, Jamaica, the Cayman Islands, Cuba, and the South Coast of the United States. Gustav caused US$15 billion in damages and claimed the lives of over 130 people. The state of Louisiana was particularly affected by Gustav, inevitably leading to widespread medical shortages. Although Hurricane Gustav was not as disastrous as Hurricane Katrina in 2005, the knock on effect was similar amongst vulnerable populations such as the elderly and diabetics. New Orleans, the largest city of Louisiana, was affected by both hurricanes and experiences gained from Hurricane Katrina have be used to improve the efficiency of medical infrastructure post-Hurricane Gustav. These improvements have proven critical in the rehabilitation of the hundreds of patients who were evacuated from hospitals and nursing homes due to direct damage caused by the impact of Hurricane Gustav, or from indirect causes such as a loss of electricity. Authorities were able to prepare for many of the problems experienced in the aftermath of Hurricane Gustav by using knowledge gained from the problems experienced after Katrina in 2005. These problems included exposure to toxic contaminants, such as carbon monoxide, when survivors crowded into makeshift shelters containing portable generators and inadequate ventilation. Standing water left after Hurricane Katrina was an ideal breeding ground for mosquitoes leaving Louisiana and other Gulf Coast regions at risk of malaria and West Nile virus. Sewage damage led to contamination of the water supply, which resulted in the spread of E.coli and the norovirus, causing numerous incidences of diarrhoea and nausea. In the aftermath of Hurricane Gustav the authorities distributed bottled water to limit the spread of water-borne disease. These measures largely helped to prevent the aforementioned adverse effects seen after Katrina 3 years ago. At present, the US authorities are continuing to rebuild the health infrastructure of the Gulf Coast, and are providing aid to affected Caribbean and Central American nations to alleviate the ongoing humanitarian crisis. In New Orleans, the population declined by 40% after these two natural disasters, but there has been a recent increase, possibly reflecting the renewed faith people have in the authorities to deal effectively with future hurricanes.

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Traditional Remedies gain WHO approval Traditional medicines hailing from South Africa to Japan such as leeches and acupuncture are set to see a greater role in modern health systems. This follows a recent World Health Organisation (WHO) conference at which representatives from 70 countries were present to discuss the use of such treatments. The WHO recognised the value of traditional remedies, not only in benefiting patients, but also as a “valuable source of leads for…the discovery of new classes of [scientifically proven, conventional] drugs”, according to the organisation’s Director General Margaret Chan3. Thus they often provide an addition rather than an opposition to Western based scientific medicine. Examples include the use of Artenisinin, a remedy isolated from the Artemisia Annua plant and used in China to effectively fight Malaria since 200BC. It is also thought that incorporating herbal and folk remedies into wider health systems will help to standardise this inherently variable genre of medicine. This already occurs in much of China, with Western and folk remedies often offered side by side. With 3 billion euros spent on ‘alternative’ remedies in Europe each year4, the interaction of traditional and ‘modern’ medicine is a major issue far outside Asia. Traditional and ‘scientific’ models of health are often portrayed as opposites, yet this conference highlighted the two in a supportive union – the union of ancient and modern, scientifically proven and (very often) unproven, and even of East and West.

Financial Crisis hits the World’s Poor Forty million more people will slide beneath the poverty line as a result of the recent financial crisis according to the World Bank. That is the real cost of the current financial crisis; a cost borne not by the traders at their computer screens, but by some of the most vulnerable people in the developing world. The NGO ActionAid calculates that the crisis will leave developing countries requiring US$400 billion over the next 3 years just to stand still in economic terms2. It seems a lot, but not in the context of the US$3 trillion already spent to shore up the developed world’s faltering banks. The worst effects of the crisis, it appears, will be suffered by countries reeling from preexisting hunger, disease, and climate related disasters. Aid agencies are united in highlighting the fact that a global problem requires a global solution; a solution which must include planning for the financial future of the world as a whole, not just the developed minority. Arguably, the world is experiencing the prospect of an intimately shared peril unprecedented since World War II. The way the international community responds (and the way its money is spent) will determine whether the developed and developing worlds exit this crisis more tightly bound or more irreparably separated. It may also dictate whether many communities in the developing world are able to survive the crisis at all.

Women’s Health in Georgia: Post-Russian Invasion There has been a severe deterioration in the health of internally displaced Georgian women in the aftermath of the conflict with Russia. As with many disasters in the world, the unique healthcare requirements of women and young girls are not being met. There is a severe lack of contraception available to young women, as well as a marked decline in screening for cervical and breast cancer. The Russian government has since endeavoured to supply humanitarian aid, but this has primarily been focused on the Northern regions of South Ossetia and Abkhazia. Conversely, the US army has been airlifting supplies to aid its NATO ally and targeted the more central Georgian areas, including the capital Tbilisi. However, most neutral observers agree that this is merely a gimmick from both sides to strengthen their foothold in this key area of Georgia, whilst ignoring the plight of over 30,000 displaced women in other regions. In the severely affected North Georgian region of Shia Kratli, the health infrastructure has been destroyed, leaving pregnant women lacking proper care and at increased risk of complications during pregnancy and delivery. Moreover, the conflict has led to an increased risk of sexual and gender-based violence, and sexually transmitted infections. Temporary shelters for internally displaced people are overcrowded, and a lack of clean water supply is exacerbating an already precarious existence for these women. Even today, the authorities are embarking on an uncoordinated approach, with Russia delivering medical supplies to the North and NATO concentrating on Southern parts of Georgia. In these circumstances, the reproductive health needs of women are often neglected as the authorities concentrate on food supplies, which generate more public support and create either pro or anti-Russian propaganda, depending on the agenda.

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Medsin UCL’s Global Health Magazine

December 2008 - Issue 2

global news o global views

Letters

Sure, Africa is poor, but at least money flows in its direction, right?

The Medsin Conference at UCL in October was very enlightening as it highlighted some of the global health issues that we take for granted. For instance, the importance of maintaining the accountability of NGOs in the provision of humanitarian aid to developing countries. Thankfully, some potential solutions were outlined, and these solutions highlighted the importance of understanding the culture and background of those you trying to help.

Well, not really. A recent report has estimated that the capital (money) leaving forty Sub-Saharan African countries amounted to US$607 billion between 1970 and 20041. When compared to the US$227 billion in external debt in 2004, it is clear that Africa is a “net creditor” to the rest of the world (i.e. its external assets amount to more than its debts). Unfortunately, while the assets that have left Africa are owned privately and do not benefit the African population, the debt that remains is a public liability which must be paid by African governments. Furthermore, even leaving debt aside, the annual US$20billion that flows out of the African economy and into the bank accounts of foreign companies pretty much cancels out all the foreign aid flowing into Africa.

Awareness of, and insight into, various cultures are necessary precursors of productive solutions to health inequalities. But who can we look to in order to provide this insight? I believe that university students have a role in providing this information. Students, through education on the harsh realities of global health inequalities, should be empowered to gain an insight into the world around them.

So Africa is haemorrhaging money! Why? Well many blame corruption among Africa’s political and economic elite, but this ignores the greed of financial institutions in developed countries which are gladly taking the money generated by African industries. Switzerland and the UK are well known culprits, yet their governments are unwilling to investigate the matter1.

In the past, many saw human empowerment as improving standards of living by the provision of technology and infrastructure. However I believe that education is now one of the principal components of empowerment. The work of student organisations like Medsin, who aim to educate and empower fellow students to make a difference, is highly commendable. However students must not underestimate the importance of volunteering in developing countries to gain firsthand experience of the cultures and people they have studied. In this way knowledge can be transferred between the students of developing and developed countries leading to a general empowerment of all people through education.

Multilateral action is required to address the problems of capital flight and tax avoidance, both of which hinder the ability of governments to redistribute wealth, and therefore contribute to growing global socioeconomic inequality2. A good time to take action would be now.

Human Empowerment; what are we missing?

Efun Akerele, Medicine, UCL

Neal Russell, Medicine, UCL

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

60th anniversary of the UDHR As the 60th anniversary of the Universal Declaration of Human Rights (UDHR) comes up on December 10th, there will be much debate as to how successful the international community has been in securing these rights for the world. Many use human rights as a banner to support their actions in one way or another. Yet surely a focus of the debate must be on whether these human rights are actually universal at all? And considering this controversy, what can we strive for in the next 60 years? Take for example the idea of female genital mutilation (FGM); it is certainly a very emotional topic and many would consider it an abuse of human rights, presumably citing Article 5 “No one shall be subject to torture or cruel, inhuman or degrading treatment or punishment”. Yet many consider it part of their culture, and they could arguably be supported in the UDHR by Article 27 “Everyone has a right freely to participate in the life of their community” We are left with a question of whether human rights can be ‘enforced’ if they have so many different meanings. The declaration was written to clearly indicate what all humans deserve by virtue of being born human. However, many assert the cultural relativist argument, that universal human rights cannot exist as we are all born in different places with different cultural values. »

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I would argue that there is a middle way, as those on both sides of the argument are actually using a universal human right to assert their beliefs, the right to a freedom of speech. After all, nobody can say that human rights are culturally relative without a freedom to do so! So, there must be some universal rights. It is surely freedom of speech that should be advocated as the central platform from which all other varying rights are asserted, so that the rights paradigm is more relevant to the world and not just Western hegemony. Akish Luintel, Medicine, UCL

ARE YOU PLANNING MEDICAL WORK EXPERIENCE IN A DEVELOPING COUNTRY? Trialled in 2007/2008, the UCL FoMSF Developing Countries Electives Database is aimed at collecting helpful information, experiences and advice from students who have been on medical work experience placements in ‘off-the-beaten-track’ countries. There has been a good response already (a sample entry is included below) and over the next year we hope to expand the collection. FINAL YEAR STUDENTS! If your elective was in a developing country then YOU can help to make this a valuable resource for UCL students. Please visit our website when you get back from your elective placement and fill out the questionnaire – it only takes 5 minutes! To have a look at the existing Electives Database, to fill in an Electives Questionnaire or to just have a look at what UCL Friends of MSF are about then go to our brand new web pages on the MSF UK Website:

www.uk.msf.org/ucl.friend Name

Oscar Leonard

Qualifying Year

2008

Type of Trip

Elective

Year of Trip

2008

Location

St Francis Hospital, Katete, Zambia

Duration of Trip

9 weeks

Contact/organisation

St Francis Hospital - found out about them from friends and read about them in medics travel guide. Website: www.saintfrancishospital.net You could go to any ward/department you wanted - adult men, adult women, paediatrics, surgery, obstetrics & gynaecology. I worked with adult men mostly and some adult women. Ward round from 8am (not so awful as you went to bed quite early). Completed the ward round with one doctor or alone. Nurses translated from local language but official language is English and all hospital staff speak English. Felt quite well supported but was scary making decisions and prescribing drugs. Ward round went on until lunchtime. Afternoons were spent doing jobs on the ward or going to outpatients and seeing lots of patients. Did lots of procedures - supervised at first then unsupervised - pleural and ascitic taps, lumbar punctures and catheterisation. Most patients had HIV/AIDS, TB, malaria or all 3. There was a free ARV programme run from the hospital. All these diseases had set regimes of treatment so managing treatment wasn't as bad as it sounds. Lived in mostly single rooms provided by the hospital away from the hospital main building. Charges were £7/day for accommodation, food and laundry so after that charge (quite steep!) living was very cheap. Hospital was quite isolated and loneliness was the main problem. Undecided - it was quite hard but worthwhile looking back.

Experience:

More or less likely to do future placements in developing countries? Advice for a similar trip? Total cost

You only get the chance to do this once so you might as well do as much as you can. Don't go alone. Take lots of books (fiction)! £2000 Transport cost £750

Living cost

£750

Grant:

£700 from British Medical and Dental Students Trust

Accommodation cost

£500

UCL FoMSF EVENTS FOR SPRING TERM 2009:

• • • • •

‘Battle of the Bands’ in association with Live Music Society and RAG Tube collection for MSF work abroad Regents Park Fun Run 2009 recruitment and fundraising Humanitarian Aid and Islam Speaker Event Showing of the documentary ‘Triage’ about MSF’s work

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December 2008 - Issue 2

The Big Debate: Will Obama bring a global health revolution? Zaneta Forson argues the case for the motion

uberculosis is on the rise, HIV is sweeping the globe, and chronic diseases are plaguing developing nations; the world needs a health revolution. I think we can all agree that initiating change has never been Barack Obama’s problem, he ran his campaign on this premise and was elected by the hopes (and votes) of millions that he would deliver on his promise of change and I believe he will. His speech on World AIDS Day 2006 epitomised his belief in change:

to Fight AIDS, Tuberculosis and Malaria1. These goals were ambitious, but foreign aid assistance is a very small proportion of America’s vast economy1, troubled though it may be. His deep-seated interest in the community, even in his pre-political days, and his inclusive patient focused angle on US health sector reforms indicates that foreign aid assistance may not be the first government program to be sacrificed in response to the financial crisis. To some, the international expectation may be naive and

“We are all sick because of AIDS – and we are all tested by this crisis. Yes there must be more money spent on this disease. But there must also be a change in hearts and minds, in cultures and attitudes. Neither philanthropist nor scientist, neither government nor church, can solve this problem on their own – AIDS must be an all-hands-on deck effort.” [Barack Obama, World AIDS Day Speech, Lake Forest, CA, 12/01/06] Obama’s comprehensive and inclusive view on global health and HIV/AIDS in particular, will help to coordinate the diverse, often antagonistic, global health programmes currently available worldwide. As a co-sponsor of the President’s Emergency Plan for AIDS Relief (PEPFAR), Obama is pushing for reauthorisation of the bill this year. So what will he change? Well, he has already promised to lift the Gag rule on PEPFAR, which denies funding to family planning organisations that offer abortion, therefore enabling US government funding to be used for family planning services in the fight against HIV/AIDS1. He has also promised to convince pharmaceutical companies to increase global access to affordable HIV treatment, and has promised to invest in long-term healthcare infrastructure in developing countries to battle HIV/AIDS1. Promises, promises, promises, the cynics amongst you cry, but I believe that much more than his financial contribution - his ethos and understanding of what is needed will lead to a global health revolution. Now let’s talk money, as ideas and promises are a start but they can’t get anywhere without funding. Today’s world presents a new challenge which the aforementioned policies and promises did not take into account. The current financial crisis has called many of Obama’s promises into question. There is an expectation to reduce government spending and focus on stabilising the American economy. Will this lead to a reduction in foreign aid? Before the financial crisis, Obama had planned to double US foreign aid from US$25 to US$50 billion a year, to donate at least US$2 billion to a Global Education Fund and to give more money to The Global Fund

Obama visiting a health clinic in South Africa Source: Chicago Tribune over-ambitious, but let’s take a look at the new world we woke up to on 5th November. The four largest economies in the world are America, China, Japan and India3, and for the first time no one sitting at the table will be Caucasian. This sends a completely different message to the world and it could be argued that people, especially Afro-Caribbeans in the USA and around the world, will be able to look to the White House and see someone that represents them and understands their needs. Desmond Tutu said that Obama’s election shows that, “for people of colour, the sky is the limit”1. The election of Barack Obama, I believe, will have a positive ripple effect, which will encourage education and ambition amongst ethnic minorities within developed and developing countries. More importantly, Obama ran his campaign on the platform of the ability of individuals to enact change in their own lives, to take responsibility for effecting the change they want to see, and to be proactive in their destinies. If we all subscribe to Obama’s belief in change then maybe we can collectively realise a global health revolution. “Change”, it is an idea, an action, a revolution and for Obama, it is simply who he is.

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December 2008 - Issue 2

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Neal Russell argues the case against the motion

hen Barack Obama was elected, most of the world celebrated. His election has brought hope, excitement, and a sense of opportunity for world change. Kenya, where his father was from, even held a national holiday! Is Obama, as the Kenyans seem to think, going to fundamentally change the way the world works? And is he going to improve global health? There are many pledges Obama has made, such as doubling foreign aid, 100% debt cancellation, tackling climate change, improving primary education, increasing funding for The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and an altogether more multilateral approach than the Bush administration’s more one sided strategy1 to global health. However, the main question is whether Obama will be able to do much in the current situation; his hands may be tied. For example, partly due to massive spending on the ‘war on terror’, the US now has a national debt of around $10 trillion, accounting for approximately 70% of the Gross Domestic Product 2. How is Obama going to fund his promises? He has pledged to increase income tax for the rich, as well as capital gains tax, both of which are long overdue, but in the current economic climate of massive unemployment there will be far fewer earners to tax. Additionally, although the position of US president is a highly influential one, Obama’s decisions and policies will be heavily restricted by internal pressure. For instance, Congress has a large influence on US foreign assistance and may block a change in policy. The American public, who will be concerned about their own wallets, and whose support for foreign assistance has often been weak3, will also influence decisions.

their markets, and whose industries may not be able to compete with their heavily subsidised US counterparts. Furthermore, global health is already being sidelined even before Obama’s presidency has started. Since Obama was elected, US officials and others have been demanding cutbacks in funding of the GFATM during negotiations in India, which could constrain Obama’s support for this multilateral fund when he comes into office4. Lastly, let us consider Obama’s plans for US healthcare5. Without going into details, he clearly wants to improve coverage of health insurance, but he is not going to overhaul the privatised system, as that would upset too many vested interests. What he has proposed with regards to US healthcare is a long way from a revolution. Perhaps his proposals for global health will be similar; maybe a bit better, but no revolution.

With two wars and the current financial crisis, global health will hardly be a priority for the US president. Obama has even said so himself that the US economy will be number one priority. Since Obama was elected by Americans, and for Americans, political pressure will overwhelmingly keep his focus on the internal state of affairs during this financial crisis, no matter how badly it affects those in the developing world. This may be a good time for reform and other leaders are calling for changes to the World Bank, the International Monetary Fund and the World Trade Organisation. Would Obama help make changes that are beneficial for developing countries? This is unclear, but it has been said that Obama is in favour of more protectionist trade policies for the US, in order to protect American jobs and industry from cheap foreign imports. Depending on the details, this could potentially be damaging for developing countries, which have already been forced to liberalise

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December 2008 - Issue 2

THE WAR ON TOBACCO: INDIA AND CHINA The world’s largest tobacco producing nations, India and China, are smoking themselves to death in a hurry, as Nisha Shah explains “Asia has become the new battleground for global tobacco control” Dr. Poonam Singh of the World Health Organisation (WHO) in New Delhi was quoted as saying in Medscape earlier this year 1. The focus of the tobacco industry has shifted to India and China, despite health warnings about the hazards of smoking issued by the WHO. A WHO working paper revised in November 2006 reported annual projections of tobacco-related deaths worldwide. It is estimated that 8.3 million deaths will be attributable to tobacco use in 2030, and in 2015 tobacco-related diseases will kill 50 percent more people than HIV/ AIDS 2, a terrifying statistic that seems all too real with the growing emergence of diseases strongly associated with tobacco consumption.

led to a significant illegal market for tobacco, which has undermined the government’s efforts to reduce consumption in many countries9. Another issue in developing countries is that consuming tobacco is a great burden on the already underfunded Due to falling demand for tobacco in public healthcare systems (only 5% of developed countries, tobacco GDP is spent on healthcare in India 7, manufacturers now have to find alternative ways to maintain demand by compared to the UK which in 2004 “exploring new markets and new spent 8.6% 8). As well as in developed 9 countries, governments of developing segments…” and concentrate on the developing world, which provides cheap countries have a social responsibility towards their people to reduce the labour and production with maximum morbidity and early mortality rates that profitability. Furthermore, in India and are strongly linked to tobacco use9. It China, the corporations have unsurprisingly targeted the adolescent would also be in the interests of governments to reduce the cost of populations through aggressive advertising in places easily accessible epidemics such as heart disease and lung cancer. to young people.

annually, according to a report published in 2003 by the Food and Agriculture organisation of the UN6. This equates to 1.3 billion smokers worldwide in 20106.

The rising demand for tobacco has increased the prevalence of heart disease, oral and lung cancers as well as Tuberculosis, which has been significantly associated with smoking tobacco 3, 4. He et al 5 concluded that smoking-related cardiovascular disease and cancer are the leading causes of death in China5. They argued that introducing smoking cessation programmes, along with other interventions, could increase longevity in China’s population.

To smoke or not to smoke?

The Growth of the Tobacco Industry in India and China It is no secret that India and China are now the world’s largest producers of tobacco and also amongst the highest consumers. Growth in tobacco consumption in developing countries increased on average by 5 percent annually over a thirty year period between 1970 and 20006. In 2000 China consumed 35 percent of the world’s tobacco compared to just 9 percent by the EU6 (See figure 1). With 320 million smokers in China alone, the number of smokers worldwide is set to grow by approximately 1.5 percent

Teen smokers in China (Source: Medindia.com) The governments of developing countries also benefit greatly from the tobacco industry, as it is a significant source of revenue for the government through taxation. It is argued that the purpose of taxation, is to increase cessation rates amongst smokers. However, increasing the price of tobacco products through taxation has

Population growth in developing countries will directly contribute to the increasing demand for tobacco. To counteract this problem, policies and interventions have to be effective in communicating the dangers of tobacco to the public. Firstly, it should be understood why it is that people smoke. Studies conducted in India, China and the West have shown commonalities in the motivations to begin smoking and maintain the habit. Although there are marked differences in cultures and social behaviours between the East and West, there are universal factors influencing smoking behaviour. Sociodemographic, environmental and behavioural factors are all involved in the onset of tobacco use10. Advertising, social norms and the increasing ease of availability of cigarettes to young people have had profound effects on adolescents’ vulnerability towards smoking10. In addition to this, Asma et al10 state that concerns of parents regarding their child’s smoking habits are focused on “school performance and psychosocial factors, including low

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December 2008 - Issue 2 academic achievement, low selfesteem and lack of skills to resist offers of cigarettes…” 10 and these concerns are salient in understanding the onset of smoking. A few studies conducted in India and China support these findings and add that socioeconomic factors should also be considered. Further studies are needed to establish health interventions to address these factors. It is, however, evident that the age of

Medsin UCL’s Global Health Magazine scheduled castes (groups of people low in the social hierarchy as defined by the government, also referred to as ‘Untouchables’) and tribes, even when confounding variables, namely wealth and education, were controlled for14. The study also showed that in India poor, uneducated populations are much more likely to smoke than the well educated and wealthy populations. The reason for this is that the former group often have limited access to primary healthcare and preventative initiatives and so they are less aware of the dangers of smoking.

smoking groups already working with the governments to target tobacco consumption. The WHO is also involved in the fight against tobacco consumption and the WHO Framework Convention on Tobacco Control was ratified by 130 nations, including India and China, and it became international law in 200518. It emphasises the importance of reducing demand for tobacco through taxation, education and various other measures. China has since then introduced plans to end all tobacco advertising by 201114. China also introduced a partial public ban on smoking during the 2008 Beijing Olympics in a bid to satisfy international pressure. India introduced a public smoking ban in October this year, 19 to follow-up the ban on tobacco advertising implemented in 2004. According to the ban, anyone caught lighting a cigarette or tobacco product would be fined Rs. 200 (approx. £2.50) on the spot.

The same study also found differences between religious groups in India; Muslim men were more likely to smoke compared with Hindu men, and Muslim women were more likely to chew tobacco compared with their Hindu counterparts. Supporting this, in a BMJ The onset of smoking is a young as 5 in letter responding to a paper by some countries Subramanian et al 16, Professor (Source: images.google.co.uk) Kawaldip Singh Semi stated that onset varies across countries, cultures religion is a key indicator of smoking India’s Health Minister Anbumani and regions. In developed countries the absence among many age of onset of smoking is on average practising Sikhs. A 15 years old compared to 18 years and religious decree forbids tobacco use over in developing countries 11. Worryingly this gap is narrowing, and in and Sikh leaders have protested against both India and China smoking is smoking and banned increasingly prevalent among 15-19 the sale of tobacco year olds and even younger in rural around the Golden areas where the onset of smoking is reported to be as early as 5 – 10 years Temple. Professor Singh stated “If the of age 13. World Health Women, Education and Smoking Organisation's Framework Convention on Prevalence of smoking amongst Tobacco Control women is also on the up. In cultures treaty…is handed to such as India the idea of a young the many Indian woman smoking, let alone a young religious groups…they man, is highly taboo. However, it is could tackle tobacco apparent that young school girls are consumption far being influenced to smoke bidis (thin, quicker than the hand-rolled cigarettes, commonly state”16 smoked in India as an alternative to more expensive conventional Bill Gates and the cigarettes) or chew tobacco. A recent efforts to promote study extrapolated that there are 41 smoking cessation million women in India who smoke or chew tobacco and this may be an underestimated figure due to Bill Gates has underreporting by household launched an antiinformants14. smoking campaign aimed particularly Anti-smoking campaigns in action A study by Rani et al14in India found towards India and (Source:google.images.co.uk) that levels of education, social status, China. Along with religion and wealth were all good Michael Bloomberg predictors of smoking prevalence14. For (Mayor of New York City), he will Ramadoss pushed for the public ban instance, according to the study, donate US$375 million to the effort17. after having urged Bollywood celebrities smoking was more prevalent amongst The donations are to fund the antito stop smoking in their movies, in fear

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Medsin UCL’s Global Health Magazine of their negative influence on young film-goers. He said studies showed that after having seen their role models smoke on the silver screen, 52 percent of these children begin to smoke 20. The smoking ban is in its infancy in India and has so far not been as effective as expected. This is partly because within rural areas there are not enough health officers to enforce the ban19. Anbumani Ramadoss, however, still supports the

December 2008 - Issue 2 developing and there is a widening gap between the rich and the poor, particularly when it comes to healthcare provisions 10. Both countries need to reach out further to the rural and poverty stricken populations and enforce better health education, whilst simultaneously reinforcing smoking cessation interventions for well-educated people and in urban regions. Michael Bloomberg said “A world without tobacco is a world in which people live longer and have happier lives,"17 China and India still have a long way to go before this ideal is achieved. Nisha Shah is a 1st year part time Masters student in Health Psychology. She chose to write about this topic because she is interested in smoking cessation and tobacco consumption in developing countries. For more information: Read the WHO report on the Tobacco Epidemic, 2008 available here: http://www.who.int/tobacco/mpower/ mpower_report_full_2008.pdf View the interactive tobacco free youth initiative at: http://www.who.int/tobacco/en/ Log onto the WHO website’s Tobacco pages at: http:// www.who.int/topics/tobacco/en/index.html

(Source: google.images.co.uk) initiative, and stated that the "smoke-free campaign is a movement launched with massive public support"19. Positive about the Future In India, the direct and indirect cost of tobacco related diseases increased from Rs. 277.60 billion in 1999 to Rs. 308.33 billion in 2002-2003, which is more than the sum total of revenue and capital expenditure on medical and public health in India in 2002-2003 21. In China, the direct and indirect costs of tobacco consumption equated to US$ 6.5 billion in the mid 1990’s 22. This is because tobaccorelated diseases cause deaths amongst the working population and so have a significant economic impact. So reducing tobacco consumption will not only benefit the economy of both governments but also reduce the heavy burden on the already fragile and inequitable healthcare services in both countries. It is encouraging to note that China showed an increase in smoking cessation of 9% this year compared to 2% 10 years ago 23. This may not be an impressive statistic; however it is a step in the right direction. There may be external pressure on the Chinese and Indian governments from the WHO and tobacco cessation lobbyists to tackle the problems of tobacco consumption, however, both countries do realise the mass implications if they do not take action against tobacco use. China and India are still

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Putting A Price On Organs Imagine logging on to eBay, and instead of seeing a pair of shoes on sale, you see a kidney. The owner of the kidney could be a lady who lives in India who has chosen to give up her organ in order to feed her five young children, or a drug addict who would prefer to have a month’s supply of the drug he is addicted to instead. However, not only does selling organs risk the health of the donor, it also challenges the ethics and morals of the medical world. Transplant trade The selfless act of organ donation means that hundreds of lives are saved every year, yet illegal organ trafficking is a huge problem, despite the numerous laws that have been put in place to prevent it. In today’s world, where the divide between more and less economically developed countries is growing wider each day, it is essential to address issues concerning the wellbeing of the international community. Due to the increase in the organ trade, nearly eighty countries signed the Declaration of Istanbul at a summit in May 2008, which stipulated a ban on organ trafficking. Nevertheless, the organ trade has augmented, particularly in less economically developed countries. Live organ donation is strongly

Source: http://www.richardseamon.com

Alisha Allana investigates how the illegal trade of organs in India, driven by poverty, is affecting the health of both donors and recipients

individuals who are poor and desperate, as it appears to be the only option for them to earn money. Kidneys, which are the most likely organs to be trafficked, are a welcome treatment for those suffering from renal failure. Even though the illegal organ trade may be a beneficial solution for both the donor and the recipient, there are some inherent dangers. Donors are often HIV positive and as these illegal donors are rarely tested before donating, there is a high risk of the recipient contracting HIV. Furthermore, operations are carried out in insanitary conditions and complications from the transplant surgery, coupled with poor post-operative treatment, could result in death for the donor or the recipient. In 1994, the Indian government passed the Human Organ Transplant Law which criminalised the sale of human organs, though this has merely led to a corrupt black market of kidney sales that occurs under the radar of the government, who are powerless to control it. A kidney for a Second-hand Car Organ trade appears to be associated more with a need to pay off debt as opposed to earning money to save for the future. However, with the average price of a kidney being £638 in India, it is not surprising that, according to a recent study carried out in Madras, 74% of the participants are still in debt six years later. In addition, the health of 87% of those who sold a kidney deteriorated after surgery. Is a kidney worth the price of a second-hand car? Can the cost of a second-hand car really be equated to a person’s good health? The World Health Organisation has called for ‘increased protection for the most vulnerable’ but for those involved in organ trade, there appears no choice.

Looking to the future discouraged as it increases the risk of organ failure in later stages of life. A solution that has been frequently However, the organ trade targets suggested is to create an ethical trade

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Source: http://www.flickr.com market, as this may be less dangerous than trade on the unregulated black market and procedures could be carried out in hygienic conditions. This has been strongly opposed by those who believe that it would not solve the growing problem, as organs would still be sold underground among the destitute; it also questions the dignity and integrity of the medical profession. Nevertheless, it is likely that the transplant trade will continue to thrive as a consequence of the huge demand for organs and the income inequalities in the world create an abundant supply of organs. Alisha Allana is a first year medical student at UCL and is interested in promoting global health issues, particularly in developing countries

For more information: Visit www.organtrafficking.org for more information Read ‘Kidney for Sale by Owner: Human Organs, Transplantation and the Mark’ by Mark J. Cherry Read ‘Black markets: the supply and demand of body parts’ by Michele Goodwin

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December 2008 - Issue 2

Mixed Methods: producing global citizenship and knowledge in local places Sharpening Data to Address Blunt Problems

Dr. Rodney Reynolds discusses the importance of multidisciplinary research teams and using mixed research methods to address global problems

data collection strategies after all suits academics’ skills.

Being able to solve problems confronting populations in various parts of the world requires richer and more nuanced information than is often currently available. This became clear to me recently while listening to Simon Reich of the Ford Institute for Human Security. Dr. Reich spoke of his involvement in efforts to eliminate child soldiers in one of this year’s “Making Things Better” lectures held at the British Museum1. Reich argued that children in conflict zones most often get pressed into military service after abduction from refugee camps. He concluded that practices based on international protocols and designed to protect camp populations often have the opposite effect, leaving children more vulnerable to strategic predation rather than less. Reich relied on quantitative data to reach the counterintuitive conclusion above. Specifically, he reports that children often get conscripted as a consequence of armed raids on poorly defended and inappropriately situated camps. Though Reich wrings a lot of detail from his data, having access only to numbers means he cannot understand how local practices, choices, allegiances, traditions and behaviors may contribute to children becoming soldiers. For instance, should one unambiguously refer to “abduction” in contexts where locals (including the children themselves) may feel children belong and have responsibilities to male cohorts, which specific ideas and practices of lineage, clan and descent would predict? Such obligations do not evaporate during war; they may get strengthened. So, how does one resist or change social practices that have valued, positive impacts for a people, as well as dire, negative ones? Qualitative research could help answer that question. The above does not intend prevarication in relation to a stubborn problem of vulnerable children. Instead, it suggests the value of mixing qualitative and quantitative methods. People around the world who would like to ensure that fewer children become soldiers need more nuanced and clearer understandings of global problems. Changing how information about such circumstances is gathered may help provide that.

(Source; google.images.co.uk) Achieving better information means bringing together researchers whose disciplinary backgrounds allow them to excel in the production of mixed data sets. But how does one enable such interdisciplinary partnerships to work? How does one persuade somebody with hard-earned, disciplinebased skills, perspectives and opinions to develop the requisite openness to do things differently — especially when trying such an approach may seem to them a drop in standards or an injunction to leave behind the authority of their discipline and its methods?

Anthropology, Multi-disciplinarity and Balancing Plural Local Knowledge

Anthropology, a social science that studies how humans (and primates) organize themselves and produce meaning, offers one possible answer. Most anthropologists would probably affirm the principle that all knowledge is particular, Obviously, some types of qualitative information might be including that which commonly gets thought of as too dangerous or difficult to obtain. This presents a research universal. Universal protocols and general solutions then problem and suggests why academic involvement in emerge from how people in a given place or discipline do addressing global questions matters. Designing productive

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“ Most anthropologists would probably affirm the principle that all knowledge is particular, including that which commonly gets thought of as universal ” things and feel and think about what they do. Anthropology reminds us that in locations where diverse health/wellbeing issues like child soldiers, global warming, witchcraft accusations and vaccination policy emerge as problems, there can be no appeal to a singular authoritative knowledge or way of working. In such locales, “local knowledge” will consist of overlapping ideas, processes and procedures that originate in various places and which are associated with various disciplines. Getting the right mix of local knowledge to get local knowledge right, without falling back on discipline or placed based authority, is hard. The only way I know to achieve such a goal is practice. If academics, policy-makers and “global citizens”, hope to achieve lasting solutions, they must invest in applied or practice based training that will accustom potential teammembers and purveyors of ideas to methods of gathering and incorporating overlapping local knowledge into their proposed solutions. In medical anthropology at UCL, we have begun to address this need through placing our

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Medsin UCL’s Global Health Magazine students with NGOs and other community based organizations, where they work with a mentor on a specific project. This represents only one solution, others exist. But to protect children in conflict zones, to rapidly adapt to a warming planet and to solve any number of problems confronting global stakeholders means adopting new ways of working and training. Dr. Rodney Reynolds, Teaching Fellow in Applied Studies, Department of Anthropology, UCL has conducted fieldwork on belonging and wellbeing in the Republic of Panama and worked with NGOs in the Antilles, Venezuela and Panama. For more information: Read “Anti-politics machine: development, depoliticization, and bureaucratic power in Lesotho” James Ferguson (1990) Read “The Rights and Responsibilities of Global Citizens: Pragmatism, Ethics, and Survival at the Coalface of Bureaucracies”. Global Citizenship and Social Movements: Creating Transcultural Webs of Meaning for the New Millennium: Routledge pp. 87 – 124 by Janet McIntyre (2000). Visit http://www.fordinstitute.pitt.edu/ (The Ford Institute for Human Security)

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Focus on NGOs

December 2008 - Issue 2 Hannah McCarthy gives us an interesting insight into the wonderful and complex world of NGOs

Non-governmental organisations (NGOs) run at local, national and international levels, campaigning and acting for basic human rights to food, water, shelter, and health for people around the world. There are large international NGOs such as Oxfam, which are world famous, but also lesser-known, small-scale NGOs like SKIP UCL. As NGOs are founded by civil society, they are free from official government intervention and so, technically, NGOs have the freedom to set their own agenda. However, in reality, NGOs are often partly funded by governments and so they are frequently influenced by them, which may undermine their agenda. Another criticism of many NGOs is that they spend significant amounts of money on advertising, money that could be spent on their projects instead. Accountability is another key issue for NGOs. Although they should be held accountable by the beneficiaries of their aid, the reality is that they are accountable mainly to their donors. This means the work of NGOs is often influenced by the desires of donors and the needs of the beneficiaries are neglected.

Established in 1981 with a vision for global access to safe water, sanitation and hygiene. Ethos: WaterAid believe that improving water access in poor communities would be the most appropriate first step in tackling world poverty. Work: WaterAid works with local communities in 17 countries in Asia, Africa, and the Pacific to establish affordable and sustainable access to clean water. There is a particular focus on women, who are given prominent positions within projects, which has a positive impact on their role within society. An example of their work is in Madagascar, where in 1999 they set up schemes to help villagers build wells and latrines. In the village of Mohairiry, women have set up a kitchen garden using a new well for watering plants, providing themselves and their families with a nutritious diet and an income from selling the surplus produce. WaterAid has also worked with local NGOs in Madagascar to introduce hygiene education and sanitation to urban and rural communities as part of the international WASH Campaign (Water, Sanitation and Hygiene for All). As a result of the advocacy work of WaterAid, the UN declared water as a human right in 2002. This exemplifies the positive effects that NGOs can have on improving global health.

Established in 1995 (stems from the Oxford Committee for Famine Relief 1942) by 13 independent NGOs from all over the world, who combined for greater impact in reducing international poverty and injustice. Ethos: Oxfam believes that respect for human rights will help alleviate poverty and injustice. It focuses on the rights to a livelihood, to basic services, to be safe from harm, to be heard, and to be treated as equal. Work: Oxfam International provides emergency relief to communities in crisis, and assistance in preparation for future crises. It also runs campaigns such as the agriculture campaign, which aims to prioritise investment in agriculture on a global scale. Increasing food prices and reduced access to farming land due to climate change have caused hunger and poverty in many parts of the world. A focus on the local agriculture industry will result in food security and job security. Oxfam also campaigns for awareness that biofuels, although a possible solution to climate change, will compromise food security in developing countries In Tunda, Indonesia where fishing is main trade, Oxfam has developed a womenâ&#x20AC;&#x2122;s programme which enables women to set up small shops to provide an alternative income to the fishing industry.

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Established in 1870 as The British National Society for Aid to Sick and Wounded in the War, it became known as The British Red Cross Society in 1908. The British Red Cross is a member of the International Red Cross and Red Crescent Movement, which both date back to 1863 and the Geneva Convention, which laid down the foundations for humanitarian law in times of conflict. Ethos: The 7 fundamental principles of the Red Cross are humanity, impartiality, neutrality, independence, voluntary, unity, and universality. Work: The neutral philosophy of the Red Cross allows them to provide aid where no other NGOs can go. In practice, this means that they do not speak out about the events they witness, unlike MSF, and so they are rarely subject to government intervention. This unique neutrality means that the Red Cross are the only aid organisation still active in certain areas of Afghanistan and at the frontline of the conflicts in Darfur, Chad and the Central African Republic. The British Red Cross, as part of the Disaster Emergency Committee (DEC) which provides immediate humanitarian aid during disasters, have recently set-up an appeal for donations in response to the current crisis in The Congo and have already raised over £4m. The British Red Cross are also active within the UK where they run first aid training programmes and they have also recently provided assistance during the national floods in summer 2007 and the London bombings in 2005.

Established in 1971 by French doctors and journalists outraged by the inadequate media coverage of the Nigerian civil war Ethos: Immediate action - MSF are normally first at the scene of humanitarian crises around the world, ranging from armed conflicts to natural disasters. They aim to provide medical assistance and raise awareness of crises by using the media. Work: In a typical project, 12 doctors are sent out to assess the humanitarian situation and begin training local volunteers. By working with locals, MSF doctors are more readily accepted by the population and gain an insight into the cultural and environmental aspects of the areas where they work. By equipping local volunteers in the field with medical skills and materials, long-term continuity of their work is assured and projects can be handed over after short periods. In 1999, MSF began an “Access to Essential Medicines Campaign” after recognising that they were inadequately equipped to treat sick patients. They aim to reduce drug costs, increase local production of drugs, and to fund research into the prevention and treatment of communicable diseases such as TB, malaria and HIV. This campaign emphasises how MSF is branching out from their initial niche of short-term action. The good work of MSF, however, is often hindered by unwanted government intervention. For example, MSF has not been given permission by the Italian Interior Ministry to continue its emergency medical screening services for EU immigrants on the island of Lampedusa in Italy. The Ministry thinks the island health facilities are sufficient, however MSF feels the facilities are inadequate to manage the changing and ever-increasing health needs of the immigrants on the island.

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December 2008 - Issue 2

A 'Traditional' Approach to HIV/AIDS: A South African Case Study Ruari Santiago McBride explains the virtues of collaboration between traditional health practitioners and conventional medical doctors in South Africa

n Issue 1 of ‘Perspectives’ Luke la Hausse de Lalouvière discussed some of the problems associated with uBhejane ('the rhinoceros cure') as a treatment for HIV/ AIDS in South Africa1. The author convincingly argued that support for the so called 'AIDS cure' was another element of the ambivalent and confusing response to the HIV/AIDS pandemic by the South African government, which has in many ways exacerbated, rather than alleviated, the country’s health problems. Proponents of the 'traditional' uBhejane remedy have been criticised for attempting to profiteer from a human health crisis and for promoting false hope among individuals who are in the most precarious of situations. However, the question must be raised; does the case of uBhejane accurately reflect ‘traditional' attempts to challenge the tide of despair caused by AIDS that is sweeping across South Africa?

cure'8 (the belief that having sexual intercourse with a virgin can cure AIDS). Another consequence has been the increased opportunity for 'AIDS entrepreneurs' to take advantage of individuals’ need to 'cure' both their physical and social suffering. The popularity of uBhejane provides an example of this kind of exploitation at work, yet also reveals

The Shortage of South African Doctors Currently, over five million South Africans live with HIV/ AIDS2. La Hausse de Lalouvière argued “ARVs [antiretrovirals] remain the best way to control HIV infection”. While this instinctively seems correct, the state of South Africa's formal health system appears to limit the impact ARVs can or will have. The formal health system currently suffers from a “chronic shortage of key health professional cadres [nucleus of trained personnel] vital to service delivery”3. South Africa has only seven doctors per ten thousand people, a frightfully low number when compared to the United Kingdom's twenty-one doctors per ten thousand4. There is also a grave disequilibrium in doctor:patient distribution within South Africa, with the majority of doctors based in urban areas, around 60% of whom work in the private sector which serves only 20% of the population5. Thus, not only are there a limited number of qualified healthcare professionals to enable the roll-out of ARVs but there are also significant health inequalities within South Africa. The rural communities and townships (areas built by the apartheid government to house non-white communities) are often the most disadvantaged areas, with the highest risk of HIV infection.

“ The state of South Africa's formal health system appears to limit the impact ARVs can or will have. ” Social Stigma In South Africa the effects of HIV go beyond the purely physiological; with infection comes social stigma6. In some instances the impact is so strong that individuals will do all they can to prevent disclosure of their infected status7. The social isolation and lack of accessible formal healthcare experienced by individuals living with HIV/AIDS has led to the acceptance of myths, such as the well publicised 'virgin

'Traditional' medicine in raw form to be mixed together by a THP the limits of biomedical intervention. ARVs may help people live with HIV, however they cannot cure the disease and are thus unable to address the negative effects of the social stigma associated with HIV/AIDS in South Africa. The promise of a 'magic bullet', like uBhejane, is often too appealing to resist for those whose illness can result in both physical debilitation and a 'social death'. However, how accurately does uBhejane represent the 'traditional' response to the HIV/AIDS pandemic? Sold in modern packaging and available for self-medication in pharmacies, it is very different from 'traditional' South African therapeutics practised by inyangas (herbalists) and sangomas (diviners)9. 'Traditional' health practitioners (THPs), with the help of the amadolzi (ancestors), diagnose and treat illness through both a person's physiology and social field10; moving beyond the individual, they incorporate

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the person's family and community into diagnosis and treatment11. Thus, the pragmatic use of uBhejane, as an egocentric treatment pathway employed independently of advice from a health professional, is far removed from the intimate care dispensed by THPs and their socially orientated methods. New roles and regulations for Traditional Health Practitioners Many traditional healers have distanced themselves from claims of their ability to cure HIV/AIDS, and collaboration between themselves and the biomedical fraternity is increasing. Such interaction is motivated towards THPs having greater access to information about HIV/AIDS and is part of the wider aim to formalise their work; a movement embodied in the Traditional Health Practitioners Act 2007, legislation designed to create an interim THP council, outline a professional code of conduct and design regulatory mechanisms for these health practitioners. Through the formalisation of THPs, it is hoped that they can work closer Communal 'baptism' in the Indian ocean to receive blessings from the amadolzi with medical doctors to educate the public and help prevent 12 further spread of HIV . AIDS Relief (PEPFAR), THPs are instructed in the prevention of communicable diseases from a biomedical In 'The Saving Lives' project currently being piloted in the standpoint, while new doctors are taught about Zulu cultural KwaZulu-Natal region of South Africa, THPs are beliefs that relate to health and effective treatment. This collaborating with their biomedical counterparts through project aims to break down the barriers of mistrust and mutual knowledge sharing and an innovative cross referral system. Sponsored by the Presidential Emergency Fund for misunderstanding built up between the two professions through years of competition and repressive legislation. Greater interaction between the two therapeutic traditions is making mutual respect, rather than antagonism, the norm and has enabled a referral system whereby biomedical doctors and THPs encourage their patrons to seek help from one another. Through acceptance of the limitations of both the biomedical and traditional health systems, guidelines for when an individual should be referred to each system have been put in place. This may happen at the primary (before infection), secondary (diagnosis of infection) or tertiary (living with a chronic disorder) level of an aliment. A hypothetical case will show how these guidelines may work in practice. A man visits his inyanga due to health related issues. After 'screening' his patron, through a physical examination and discussing his social relationships, the inyanga comes to the conclusion that the man may have contracted HIV and refers him to his local hospital for this to be confirmed. The hospital staff confirm that the individual is HIV positive, but is not eligible for ARVs as his CD-4 count is over two hundred (the level below which an individual is entitled to receive ARVs in South Africa). The hospital refers the individual to his THP who can help the individual at this crucial stage of his condition, by promoting a healthy diet, encouraging the use of condoms, explaining the importance of a monogamous relationship offering support and advice, offering support and advice, and crucially, persuading the individual to disclose his status. Once the individual's CD-4 count is below two hundred, both biomedical staff and THPs will play a role in ensuring that the individual adheres to his drug treatment and maintains a healthy lifestyle. 'Traditional' medicines available for self-medication from pharmacies

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December 2008 - Issue 2

for the benefit of social health. It is only through the incorporation of THPs into the formal health system, as is currently happening in South Africa with the Traditional While many socio-economic barriers may come in the way Health Practitioners Act 2007, that the country can begin to of such a case being as smooth as my idealised outline formulate new strategies with which to overcome the HIV above, it nevertheless represents a possible scenario in pandemic. ARVs may be one answer, but they are only part which THPs and biomedical practitioners work together in order to support individuals living with HIV/AIDS. The central of the larger solution. position of THPs within the social and cultural life of the Ruari-Santiago McBride has just completed the MSc in people of South Africa, combined with their intimate physiological and cultural knowledge, grants them the ability Medical Anthropology at UCL, during which he conducted two months qualitative fieldwork research in KwaZulu-Natal, to positively impact the HIV pandemic, often during moments when biomedicine is inaccessible or powerless to South Africa on 'Policy and Process: The Management of a Therapeutic 'Tradition' in South Africa' help; the difficult moment of disclosure, promotion of a healthy lifestyle, and in challenging entrenched stigma. It has been suggested that by adapting 'traditional' public cleansing rituals held at the beginning of most therapeutic journeys, which use muthi (medicine) to purge illness from For more information: the body, THPs could empower those living with HIV through a “real and powerful healing of the emotional Read “Three-Letter Plague: A Young Man's Journey distress of the disease, for the client, their family and Through a Great Epidemic” by. Steinbeck, J. 13 community” . THPs could, therefore, positively challenge and change communal perceptions about HIV in culturally Read “Witchcraft, violence and Democracy in South appropriate ways that biomedical practitioners cannot, Africa” by Ashforth, A. subduing the desire for a miracle cure in the process. A Successful Collaboration

In a country with a degrading health system and a significant HIV/AIDS burden, South Africa cannot afford to ignore its two hundred thousand THPs13. Through mutual respect and knowledge sharing, practitioners from both health care domains can collaborate on a level previously unimaginable,

Read “Sincedisa – We Can Help: A Literature Review of Current Practice Involving Traditional African Healers in Biomedical HIV/AIDS Interventions in South Africa” by Wreford, J. (2005) in Social Dynamics 31(2): 90-117.

MA in The Philosophy, Politics and Economics of Health Hardly a week goes by without a new health controversy. Phrases like ‘the postcode lottery’, and the notion of a quality adjusted life year, feature in everyday discussions of health resource allocation. These are questions in the Philosophy, Politics and Economics of Health. Located in the UCL Centre for Philosophy, Justice and Health, an innovative new MA programme in the PPE of Health will start in 2009-10. The programme will explore the central ethical, economic and political problems facing health policy worldwide with particular emphasis on issues of social justice.

For further details please contact the course director Professor Jonathan Wolff at j.wolff@ucl.ac.uk or visit our website www.ucl.ac.uk/cpjh/MAprogramme

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Interview: A Lawyer in the World of Medics Médecins du Monde (MdM) is an international humanitarian aid organisation which provides healthcare to vulnerable populations in both developed and developing countries. Hannah Rees meets with the MdM UK Director, Susan Wright, to discuss her unusual but fascinating career path.

s I meet Susan Wright after one of her workshops at the Medsin UCL National Conference, medical students are still inundating her with questions on the reality of working overseas. Wright, however, did not pursue this medical route to her current role as Director of Medecins du Monde. In fact, she is one of only two lawyers within the organisation, which has about 5000 staff, the majority of whom are from the medical profession. Before joining MdM in 2006, the American lawyer’s career included teaching International Criminal Law, trialling criminal war crimes in Bosnia and Herzegovina and Sierra Leone, as well as “typical clinical practice” in the US with “typical murder cases”. Wright professes that her career path may look a little “strange” to outsiders, as she has not had the most “typical career path as a lawyer”.

MdM UK Director—Susan Wright

Development (DFID) and Irish Aid. This does not simply mean sending off letters asking for money, the process is far more intricate than that. By following reports released by potential donors, she identifies which of their policies The three realms of a successful may overlap with the work of MdM. career Different strategies used by different donors must also be considered. For Susan Wright’s initial attraction to MdM example an MdM project in Iraq gained funding from Irish Aid, but not from was because the non-governmental DFID, due to the UK’s involvement in organisation does not simply provide assistance where the need is greatest, the war. Thus, Wright proclaims, “in a sense I could say its mundane but sees that there are needs virtually fundraising, but its not – its policy”. This everywhere, just at different levels. It was upon this basis that MdM's Project: extends to “affecting change relative to European policy”, by liaising with MdM's London emerged; a one-off medical clinic and advocacy programme aimed European offices, as “there are more and more policies taken at Brussels”, at those living here in the UK, without thus MdM must amend their own access to healthcare. However, a policies in response. further attraction to the job for Wright was the ability to balance her practical discipline, the law, with education, and A few words of Advice being able to pass on her knowledge to So what advice does Wright have for influence policy. She sees the anyone wanting to pursue a career in synchronisation of these three realms with the ability to “move seamlessly the humanitarian aid and advocacy amongst them”, while producing a field? Firstly, contrary to common belief, she does think it is “great to have this “maximal impact”. romantic idea of changing the world; its something that we should admire – both One of Wright’s key roles lies in fundraising from donors such as the UK in ourselves and in others. I think it is a strong human impulse”. Yet Department for International

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simultaneously she confesses that a personal 'pet hate' is when someone exclaims that they are “superpassionate”. This passion, according to Wright, must be backed-up by relevant skills, and a confidence in ones own skills; a necessity when thrown into difficult situations. Secondly, you should be able to articulate your desire for doing humanitarian work to others. Thirdly, do not hesitate in approaching anyone who has been of great interest to you, be it in a lecture or elsewhere, especially if they are really happy in what they are doing. Wrights final note of advice: “you cannot think of work overseas as a 'break from the real world' or a 'break from your career' – you have to figure out a way to integrate the two so that your overseas work makes your UK work better, and vice versa”. Hannah Rees is a 3rd year Human Sciences student, currently volunteering as a Support Worker at Project: London For more information: If you are interested in volunteering for Project: London or wish to find out more about MdM, visit the website at: www.medecinsdumonde.org.uk

Medsin UCL’s Global Health Magazine

December 2008 - Issue 2

Politics and Healthcare: A Tale of Two Democratic States Kimberley Annabelle Myers compares the healthcare systems of two very different democratic states

British in 1962 and its political system is public healthcare facilities. This was met with widespread approval from the democratic with a British based electorate as up to that point many parliamentary system of governance. Jamaicans felt that they were unable to access healthcare as much as they Healthcare in Jamaica is divided into would have liked. public and private sectors. The public sector has always been subsidised to varying extents by the government, regardless of which political party is in power. Currently, Jamaican citizens who access public healthcare pay no user fees for the most basic services WHO Commission on The Social including diagnostic laboratory and Determinants Of Health, September imaging services, day surgeries and 2008 medication from hospital pharmacies. Private health insurance plans are also A country's political structure affects available to private and government virtually every aspect of society, workers. The biggest health problems including health. that the island faces are chronic Democratic nations are referred to as the “free world” where its citizens have diseases of affluence such as an active role in the management of the hypertension and diabetes mellitus. Prevalence of these conditions between nation’s business and where the elected government is held accountable 1992 and 1995 were 21.09% for males by its electorate. Access to healthcare and 27.67 % for females.2 should be a basic right for all citizens in Prime Minister of Jamaica, Bruce Golding any state. However, there remain some The economic burden of diabetes mellitus and hypertension in Jamaica in The Jamaican Labour Party’s health nation states that are yet to achieve plan, as stated in its election manifesto, health equality for all their citizens. This 2004 was estimated to be more than asserts that “We are irrevocably US$330million 2. In order to address article will analyse and compare the committed to the view that it is the duty this growing problem, the Jamaican healthcare systems of two democratic Western states: Jamaica and the United government set-up the National Health of the government to provide unrestricted access to basic health Fund in 2003 which helped increase States of America. access to pharmacological treatment for services” 4. In addition, the present government plans more intensive public chronic conditions. Medication is now Jamaica: Health for All, Eventually available from participating pharmacies health management, improved primary at government-subsidised rates, which healthcare delivery, telemedicine technologies and an increased number save thousands of Jamaicans from all of tertiary centres of excellence in social classes a significant amount of specialist areas. 4 money. It is currently financed by increased taxes on tobacco products However, despite unrestricted access to and a salary reduction of 1%3. health services, citizens still face problems such as long waiting times to However, subsidised user fees for see physicians and undergo surgery. In public health facilities and cheaper drugs were not enough to address the addition, the public healthcare sector in Jamaica is lacking in several specialist burden of chronic disease due to services and the availability of these increasing costs of living. So in April services outside of the public system is 2007, the government abolished user limited and costly. Therefore, although fees for children accessing the public Jamaica is a Caribbean island that is primary healthcare is now freely healthcare system. Following the world renowned for its culture and available, many health problems are election of a new government in music. It is home to over 2.5 million September 2007, the Jamaican Labour still inadequately treated as citizens are people of varying ethnic backgrounds Party led by Bruce Golding removed the unable to afford costly secondary or and a mixed free market economy. tertiary healthcare services. Jamaica gained independence from the user fees for all Jamaicans accessing “A girl born today can expect to live for more than 80 years if she is born in some countries – but less than 45 years if she is born in others. Within countries there are dramatic differences in health that are closely linked with degrees of social disadvantage. 1”

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December 2008 - Issue 2 United States of America: Hope for Change

Medsin UCL’s Global Health Magazine the government to provide basic health coverage for all its citizens. Currently in America, there are only governmentadministered plans for citizens aged 65 and over (Medicare) and limited categories of low-income families (Medicaid). Many citizens remain uninsured as a result of the restricted national health insurance programs and costly private schemes.

On 4th November 2008, American citizens elected Barack Obama of the Democratic party as their new president. He will start office on 20th January 2009 with much hope and anticipation for positive change. The American Medical Students’ Association (AMSA) created a scorecard, to look at the healthcare plans of each presidential candidate, and this was their verdict on Presidentelect Obama: “Through consideration of the increasing hardships working families face in paying for their healthcare, The United States of America is one the Senator Obama has prioritised making quality healthcare affordable for all leading nations in modern healthcare technology and research. However, it is Americans”.7 well documented that accessing The President-elect’s healthcare plans healthcare services is costly for the average American, with most American include formation of a national health insurance exchange scheme to formally citizens and immigrant workers regulate the private insurance market depending upon private health insurance schemes as the government and thus allow for affordable access to health insurance for all. The cost of contributes very little to healthcare financing5. As a result, many are unable insurance would be dependent on one’s to afford doctors and those with chronic income and not on their health risk. This will reduce discrimination against medical conditions are trapped into those of lower socio-economic class insurance schemes which are and a prior medical history, therefore extremely costly. Approximately one preventing insurance companies from million Americans declare bankruptcy only insuring rich and healthy every year in the struggle to pay off individuals7. Furthermore, small their medical bills.5 businesses would be provided with In March 2008, a study entitled ‘Support government subsidies enabling them to for National Health Insurance amongst provide affordable health insurance U.S. physicians: 5 years later’ was plans for all their employees. These ‘average Joes’, as John McCain so released. It analysed the physician eloquently put it, comprise a large support base for the idea of having a national health plan.6 Reflecting a shift sector of the workforce and unfortunately are often not able to in thinking over the past five years afford health benefits.7 Obama’s plan, among American physicians, the new study showed that 59 % now supported however, has not provided any details national health insurance, an increase on health benefits for illegal residents. of 10% since the study was previously This is a very topical issue in many developed countries because these carried out in 2002.6 Dr. Ronald T. Ackermann, the co-author of the study, countries have become lands of states: “Across the board, more opportunity for citizens of developing physicians feel that our fragmented and countries.7 for-profit insurance system is Putting it all together obstructing good patient care, and a majority now support national insurance as the remedy.”6Any national health Healthcare is one of the most important insurance plan should be organised by election issues for voters everywhere in

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the world. Political parties recognise this and healthcare reforms are a key focus of all election campaigns. The strength of these reforms are usually critical in winning over the electorate.

“ Approximately one million Americans declare bankruptcy every year in the struggle to pay off their medical bills ” It is clear that even with the freedom of choice that comes with democracy, citizens still face health inequalities due to poor government administration and regulation of health systems. Jamaica is a developing country which has been able to create a health system that is universally accessible and affordable whereas the United States still awaits the ideal of universal access. Jamaican citizens do still face challenges in receiving quality healthcare due to inadequate staffing coupled with increasing demand, whilst many specialist services are simply unavailable or unaffordable. The United States, on the other hand, has the resources to provide universal healthcare and maybe this is the change we will see with Barack Obama. Kimberley Annabelle Myers is a final year medical student at the University of the West Indies, Jamaica and has a passion for civil rights equality and justice for all.

For more information: Read the “Commission on the Social Determinants of Health Final Report” by the WHO, September 2008 http:// www.who.int/social_determinants/en/ Read “A Politics of Health Glossary”(2007) by Bambra C, Fox, D And Scott-Samuel A. in the Journal of Epidemiology Community Health 61: 571-574. Read “Health and the Millennium Development Goals” by the WHO, September 2008

Medsin UCL’s Global Health Magazine

December 2008 - Issue 2

Tribal Medicine and The Art of Ancient Healing Natasha Lyons provides a present-day perspective on the weird and wonderful pursuits of medicinal magico-religious practice From the concrete battalion of Western civilization, where the might of Anglo-medicinal practice is deeply entrenched within our souls, it is hard to imagine an entirely disparate approach to ill health. Modern day alternatives to the mainstream approach attract only the bored middle-aged women of the middle classes, with their dubious pots and potions safely constrained to the shelves of “Holland and Barratt”. Put simply, our approaches work: if an ancient hunter-gatherer was to be hit by a hypothetical bus, his body would not last long enough to be shocked back to life, undergo dramatic facial reconstruction and (most probably) develop post-traumatic stress disorder. But our way cannot have always been the only way, and indeed, still is not. Lurking deep beneath the reaches of our cultural ignorance lie the oddities of ancient practice, little known to the medical minions of the West. The previously revolutionary notion, that medicinal drugs should be used to treat specific diseases, has become so embedded into our health culture that it becomes difficult for us to accept that this concept has only been around for the last hundred years1-.

Shamanic Healing One alternative interpretation of human illness considers the maladies of the body as evidence of malevolent influences, such as evil spirits6. The practice most famed for its collaboration with the spirit world is shamanic healing, which has been adopted by many tribes-folk in Korea, Siberia, the Americas, Africa and rather peculiarly, amongst a number of Eskimo groups in Greenland and Alaska7. The Shaman’s ritual of ‘personalistic’ healing attempts to remove a physical

“ Should the spirit prove to be feistier than your average, a ceremonial group beating of the afflicted takes place, often with sticks” The Tribal Philosophy By contrast, ancient medical techniques endeavour to treat the person as a whole, as opposed to the afflictive disease.2 Such practices rely on the healing powers of the human as opposed to pharmaceutics, with the fate of the patient left to a colourful array of unpredictable deities, rather than to our decidedly earth-bound medical establishment. It is these techniques that comprise the many pursuits of tribal medicine, such as those of the shamans, the aboriginals and the Native Americans3. We humans share a curious social trait with all our domesticated beasties, which enables us to imprint the ideal of leadership onto other members of our species, who we will then aimlessly follow and obey4. However, we are the only creatures to have been inclined to assign the fate of our good health to the whims of the mystique5. Though theories behind the causes of ill health may vary wildly across the globe, our faith in the medical power of the person, whether armed with drugs or magical forces, can be seen to be a near universal human trait.

Shamanic Eskimo Healer Source: Collections of the Library of Congress evil ‘thing’ or object from the body and resembles a rigorous physical assault on the ill fated invalid8. To bring the disease to the surface of the patient’s body, the shaman healer will repeatedly pound his client, pummel the flesh and leap on and off the torso9. Once the disease has risen to the body surface and the site of the demonic affliction has been located, the healer will then salivate onto the point of infection to transfer his ‘power’ to the infirm10. With a bit of luck, the healer’s power, being of immeasurable strength, will prevent the patient from succumbing to the disease and when the healer calls back his power, the patient will be ‘cleansed’ of the irksome spook11. However, should the spirit prove to be feistier than your average, a ceremonial group beating of the afflicted takes place, often with sticks, while others present morbidly sing and drum at an increasingly loud volume12. Finally, the healer rises from the side of the

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December 2008 - Issue 2

Medsin UCL’s Global Health Magazine

patient with the disease carefully cupped in his hands, and particularly ill fate some time in the near future.24 Following the musical calamity ceases13. The sickness is then this mighty ‘vomithon’, a “bull-roarer”25 (which is literally a banished from the surroundings a total of four times (through stone on a string which roars) is sounded six times, and then applied to all the patients26. The Chanter’s assistants then carry the vomit-basins out of the Hogan, followed by the audience and then the newly cured. The ritual intends to restore the balance of good and evil within the patients 27, by expelling the bad and attracting the good via sand painting and group chanting. However, for the Cherokee, the ethos behind the vomiting rite is much more simplistic. Illness is thought to be the result of gastric imbalance 28 which can be caused by witchcraft or suspect cuisine 29, so vomiting asserts itself as the most logical therapeutic cure within this culture. Not that Different After All

Navajo Ceremonial Mask Source: http://www.old-picture.com/

Though these ancient magico-religious practices may appear to be utterly eccentric by today’s standards, if the ideology and faith behind these rituals are examined, the medical approach of the ancients seems increasingly logical. Instead of identifying the micro-invaders of the body as the cause of disease, our ancestors attributed illness to the grumps of the supernatural, so in this sense, the greatest threat to our survival has always been from the enemy that we cannot see. Throughout the history of civilization, humans have sought to rationalise forces that they cannot explain, to prevent the infuriatingly confusing concepts of the universe from driving the population insane30. The present day’s incorporation of physics into the school curriculum has shattered this protective mind shield for most of us, but thankfully, the understanding of both human disease and ourselves has been elevated from the ranks of such ‘insaneogenic’ uncertainties.

Humans have always shared the common faith that if we are either a smoke-hole, or just the door)14 before the fastidious able to woo the powers that be, whether they are spirits, healer is satisfied that his brutal, yet cost-effective Gods or medicinal drugs, then an individual can adopt the power to cure the pathological afflictions of others31. Within alternative to antibiotics has conquered the sickness. Western societies, these various ancient beliefs have transcended to a uniform trust in the medical profession and our causation theories have substituted demons for Hogans and ‘Vomithons’ diphtheria and spirits for syphilis. However, though our pragmatic practices and use of synthetic drugs in the Many Native American tribes, such as the Navajo people 15 treatment of disease are undoubtedly more savoury pursuits and the Cherokee, also perform purification rituals . However, their techniques rely on the ancient art of vomiting than group vomiting, the minds of the medically persuaded to rid the body of evil16, as opposed to grievous bodily harm. human, whether ancient, tribal or modern, may not be as The Navajo ‘sweat-emetic rite’17 begins with the creation of a different as one might have originally assumed. ritual hut, or ‘Hogan’18, complete with a central fire and sand rd paintings. A Chanter leads a procession of sickly individuals Natasha Lyons is a 3 year Human Sciences student at into the Hogan, and then proceeds to circle the fire, pausing UCL and is particularly interested in the history of pharmacology and spiritual treatments used in various briefly at each of the four directions to sing an appropriate 19 regions of the world. chant . In some ceremonies, the men are required to successively leap over the fire, though this is not strictly necessary20. An audience enters the Hogan after the procession, just in time to witness the Chanter plunge a wooden poker into the fire, before searing it onto the chest and then the legs of the invalids21. Each patient is presented with a basin of emetic formula22, everyone walks around the fire again and the liquid is drunk and vomited back into buckets filled with sand23. Vomiting is strictly compulsory, as anyone who fails to spew out the evil within will be expected to meet a

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For more information: Read “A Medicine Woman Speaks: An Exploration of Native-American Spirituality” by Cinnamon Moon Read, “Anthropology of Symbolic healing” by Moerman et al, Current Anthropology. 1979. Vol 20, pp59-80 Read “God, Medicine, and Miracles: The Spiritual Factor in Healing” by Daniel Dr Fountain

Medsin UCL’s Global Health Magazine

December 2008 - Issue 2

As easy as ABC? Natalie Barry looks at the complicated and often neglected issue of gender inequality in the HIV Epidemic in Sub-Saharan Africa

common mode of transmission globally5, 6. In answer to this, widespread implementation of ABC programmes has been seen throughout SubSaharan Africa, with millions of dollars invested. The ABC approach is a globally adopted strategy, promoting Abstinence, Being faithful, and the Correct and Consistent use of Condoms as the cornerstones of HIV prevention7. In 2003, George Bush committed 20% of the PEPFAR (President’s Emergency Plan for AIDS Relief) budget of US$15 billion over 5 The UN Millennium Development Goals years to HIV prevention programmes, (MDGs) have set out global targets for many of which were underpinned by ABC8. Evidence suggests that ABC is 2015 which include commitments to working in Africa; and Uganda is often address the triple threat facing Subcited as a success story for the Saharan Africa: Poverty, Gender Inequality (MDG3) and HIV (MDG6). It approach, with a fall in HIV prevalence from 15% among adults in 1991, to a is clear that these three issues are current estimate of 5.4%. However, inextricably linked. The UN task force on HIV and Women stated “if we can even in Uganda, the 7.5% prevalence stop the spread of HIV among women amongst women is significantly higher and girls, we can turn the epidemic than in men (5%)9,10. 3,4 around” . Women are still getting infected at a faster rate than men, and this is not only true for sex workers or women with multiple partners. In fact, studies in South Africa show that women under 20 who were married had higher rates of infection than those who were unmarried but sexually active5. In 2004 UNAIDS reported that the ABC approach is insufficient as it is not addressing the realities of women’s lives. UNAIDS deputy executive director, Kathleen Cravero stated “We tell women to abstain when they have The Limitations of ABC no right. We tell them to be faithful An important contributor to the statistics when they cannot ask their partners to be faithful. We tell them to use a is women’s biological vulnerability to HIV. They are twice as likely to become condom when they have no power to do infected during sex as men, as they are so”5. Geeta Gupta, of the International exposed to a larger dose of the virus, Centre for Research on Women, and heterosexual sex is the most n 2003, former United Nations (UN) General Secretary Kofi Anan stated “AIDS has a woman’s face”1. His statement was echoed in 2008 by the UNAIDS (Joint UN Programme on HIV/AIDS) annual report, which showed that in Sub-Saharan Africa women account for 59% of all HIV cases and girls aged 15-24 are nearly 3 times more likely to be infected than men aged 15-24. In South Africa alone, 15% of women aged 15-24 are HIV positive compared to 5% of males of the same age2.

reported to UNAIDS on the factors contributing to women’s lack of power in sexual relations. According to Ms

“ The ABC approach is insufficient as it is not addressing the realities of women’s lives” Gupta, gender is a cultural and social construct that differentiates women from men and defines the ways in which they interact with each other. Sexuality, she says, is influenced by one’s age, gender, economic status, and ethnicity. Power is fundamental to sexuality and gender, and an inequality in gender relations that favours men translates into a similar inequality in sexual interactions where male pleasure is prioritised. Men therefore have greater control over when, where, and how sex takes place within marriage11. The Culture of Gender Inequality Research in South Africa has examined some of the ways that cultural ideas around gender create inequality. It was reported that culturally, women are expected to place their partner’s sexual needs before their own. Social worth is often defined by a woman’s ability to retain a male partner. These cultural expectations combine to hinder women from requesting condom use, through fear of relationship breakdown. In many cultures, unmarried women face a different set of problems as it is not acceptable for them to have sex. As a result, sexually active, unmarried women are unable and unwilling to seek contraceptive advice from older peers and family members12.

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December 2008 - Issue 2 This wall of silence is further compounded by the lack of education. Two thirds of the world’s illiterate population are women and this is reflected in Sub-Saharan Africa. In addition, UNAIDS reported in 2008 that only 38% of women have access to comprehensive information on HIV. There is a well-documented relationship between poor education and the efficacy of contraceptive advice. Studies in rural South Africa have found that many women disliked condoms, as they mistakenly feared that they could fall off and travel to another part of their body13. Another factor contributing to women’s fear of safe-sex negotiation is that of intimate-partner violence. The violence is often associated with increased HIV infection rates and there is much evidence to support this link. For example, one study in Tanzania found that women who attended a voluntary testing clinic and tested HIV positive, were 2.6 times more likely to have experienced violence than those who tested negative14. Simultaneously, the refusal of sex, questioning the fidelity of ones husband, and the suggestion of condom use, have all been described as triggers for intimate-partner violence, yet these factors are fundamental to HIV prevention12,14.

“ Traditional customs and statutory laws limit a woman’s independent entitlement to land or housing” There is also an issue of economic gender inequality, which undermines women’s ability to become empowered and independent. According to the UN, 70% of the world’s poor are women15. Throughout Sub-Saharan Africa, traditional customs and statutory laws limit a woman’s independent entitlement to land or housing, and dictate that she must give up these entitlements in the event of marriage breakdown or death of a husband, leaving these women vulnerable to poverty and destitution1. Research has demonstrated that economic

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Medsin UCL’s Global Health Magazine vulnerability increases the likelihood that women will exchange sex for money, whilst decreasing the likelihood that they will successfully negotiate safe-sex or leave an unfaithful relationship11, 12. What is being done? MDG3 embodies the UN’s aim to promote gender equality on a global scale, and there is hope that HIV incidence amongst females will subsequently be reduced.

initiatives have been used as a means of empowering economically disadvantaged women. The IMAGE study, conducted in South Africa, recruited the poorest women in eight communities and offered them small business loans in order to buy and sell produce. The intervention addressed issues such as HIV, sexual violence and gender equality, along with business training. Over 2 years there were statistically significant increases in economic wellbeing, a 55% reduction in intimate-partner violence, and a 24% decline in episodes of unprotected sex. Similar micro finance initiatives are now being implemented in Uganda, Rwanda, Togo, Zambia and Zimbabwe1, 18,19.

To tackle the immense and complex issues around poverty, gender inequality, and HIV is an overwhelming task. But, there are signs that global and African leaders are recognising the A microbicide applicator need to couple poverty reduction and Source: Caprisa female empowerment with HIV prevention strategies21. The ABC Biological hope for women may lie in a approach only presents a viable option for women if it is part of a package that microbicide gel, which can be applied inside the vagina. It has been billed as takes into consideration the cultural and economic barriers they face within their a female-controlled HIV prevention communities. Addressing the cultural method that women could utilise without telling their partner, and the gel issues, providing economic initiatives is currently undergoing extensive trials. for women, the distribution of A microbicide that is 60% effective and microbicides, and the changing of used by one in 5 women, could prevent women’s property and inheritance laws, 2.5 million HIV infections over 3 years, might collectively represent an effective and studies show that both women and solution to the plight of women and their HIV burden1, 5,18,19. men would favour its use over that of condoms. However, microbicides only represent one potential solution to the Natalie Barry is a 5th Year Medical multi-factorial issue of female Student at UCL, who has a particular disempowerment. It is even possible that widespread microbicide use could interest in global health in relation to lead to a further reduction in the use of women. condoms, which is in itself a worrying thought5, 13,16,17. For more information: Progress is being made in other areas Get involved with the Medsin UCL Stutoo. South Africa recently introduced dent Stop AIDS Campaign by visiting the Customary Marriages Act, www.uclmedsin.org/stopaids.htm mandating that a woman no longer becomes the property of her husband’s family when he dies, thus safeguarding Read “HIV and AIDS in Africa: Beyond Epidemiology” by Ezekiel Kalipeni her independence and entitlement to household assets. Similarly in Kenya, the government has recently appointed Read “Reclaiming Our Lives: HIV and a Ministry of Gender, and a constitution AIDS, Women's Land and Property Rights and Livelihoods in Southern and protecting women’s property rights. East Africa, Narratives and ReOther countries are expected to follow sponses” by Kaori Izumi suit1. At a community level, micro finance

Medsin UCLâ&#x20AC;&#x2122;s Global Health Magazine

December 2008 - Issue 2

SKIP UCL: Health Promotion in Ghana Anushka Thalayasingam explains the work and ethos of SKIP UCL, an international project run by students at UCL SKIP (Students for Kids International Projects) is a registered charity, which is run by healthcare students who hope to improve the lives of vulnerable children worldwide through sustainable interventions and community development. There are SKIP branches at 17 UK universities, which support projects in countries including Madagascar and Sri Lanka. The SKIP UCL branch was established in 2005 and after much initial research, we chose to set up a project in Tongo, a rural village in Northern Ghana. This village was selected as there are many young, single mothers in this community who we believed could benefit from our help.

in Ghana die before their fifth birthday1. Between 2000 and 2003, 12% of deaths among children under 5 years old were due to diarrhoeal diseases1. Motivated by such disheartening statistics, SKIP UCL decided to work towards improving health education in Tongo. Last summer, we collaborated with local health workers and translators to deliver a series of talks which aimed to educate the community on how to protect themselves against disease. These seminars were focussed on recognising characteristic symptoms of disease and promoting the importance of handwashing, drinking clean water and administering oral rehydration therapies to children suffering from diarrhoeal diseases. Importantly, SKIP UCL ensures that any interventions implemented are both sustainable and culturally sensitive. Our ultimate aim is for SKIPâ&#x20AC;&#x2122;s presence in Tongo to become obsolete; we want the young mothers and children to build on the foundations we have set up in Tongo and become independent from our support. That is the SKIP ethos, a hand-up, not a hand out.

Some of the children posing in front of the training college SKIP UCL built.

Anushka Thalayasingam- is on the organising committee of Skip UCL and is in her fourth year of studying Medicine at UCL. She is interested in the issues which result in the discrepancies in access to healthcare and health awareness between and within countries.

Our work in Tongo SKIP UCL observed first hand that unfortunately, once pregnant, many of these young women in Tongo lose the support of their partners. The young men of the village are frequently lured away from their paternal responsibilities by the promise of employment and excitement in the large cities. Consequently, the mothers often struggle to support their children and themselves financially. In addition, many of these women are forced to drop out of school when they become pregnant. Without any qualifications, it is almost impossible for them to gain formal employment. In the summer of 2007, SKIP UCL converted a disused building in Tongo into a vocational training college in order to teach the young mothers skills such as dressmaking and hairdressing. This training gives the women the ability to earn a regular income and with this, the hope that they will be able to secure a better future for themselves and their children. SKIP UCL students also set up and ran a summer school for the children of these mothers where English and art were taught to the children. Building Sustainable, Independent Communities The World Health Organisation reported that 12% of children

Posters were used in health awareness talks For more information:

Please visit the SKIP website: http://www.skipkids.org.uk/ If you are interested in volunteering at the project in Tongo this Summer and/or in fundraising for SKIP UCL, please contact us by email (skipucl@hotmail.co.uk) . SKIP is primarily open to students whose degree programmes are registered under the Faculty of Life Sciences, but everyone is welcome to contribute to fundraising.

http://www.uclmedsin.org

December 2008 - Issue 2

Medsin UCL’s Global Health Magazine

International Aid: Not Just About the Money Through her work with the charity organisation Lepra, Iram Zahid discovered the importance of addressing social stigma when implementing an aid project

here are many debates about whether international aid actually causes more problems than it solves. Quite often, owing to corruption or an inefficient utilisation of aid, it does not reach those who most need it. Rather than just looking at how much money is funnelled into various projects we should also consider how this aid is administered.

then how can they be reached and educated? Lepra sets up regular ‘undercover’ focus meetings that allow the men to talk openly about their sexual habits and learn about the risks they may be exposing themselves to.

By 2010 Lepra aim to further raise the profile of neglected diseases worldwide, and address the associated effects of discrimination and stigma. Lepra’s work has shown that overcoming social barriers plays a key role in reducing the In any case, financial aid is not enough to overcome the global burden of disease and poverty alone. There are many prevalence and impact of disease. When international aid is given it should be implemented in a manner that takes into social issues that must be addressed too. One charity that addresses these issues is Lepra. Lepra is a medical charity account all sections of society and addresses the specific social circumstances within which disease occurs. This has which primarily aims to prevent and treat Leprosy. I met some of Lepra’s UK staff during my gap year in India and, as been the key to Lepra’s success in India. a result, I was able to visit some of their projects in Iram Zahid is a second year Human Sciences student at Hyderabad and see just how effective their work was. UCL, and became interested in global health whilst volunteering for Lepra during her gap year in India How does Leprosy affect People’s Lives? Leprosy is a chronic disease and if left untreated it can cause permanent damage to the skin, nerves, limbs and eyes³. The most susceptible are those living in unhygienic conditions with inadequate water supplies and diets. Contrary to popular belief Leprosy is not highly infectious, however there remains a significant social stigma attached to it; many people will refuse to shake hands with leprosy sufferers for fear of contracting it, husbands may divorce their wives if they have leprosy, and certain employers will sack their employees if they are found to be infected.

For more information: Visit http://www.lepra.org.uk Visit http://www.who.int/lep/en/ Read “Social Development of Commercial Sex Workers in India” by Amit Chattopadhyay, Rosemary G. McKaig. in AIDS Patient Care and STDs (2004) 18(3): 159-168

It is because of this stigma that many people refuse to see a doctor until it is too late and irreversible nerve damage has occurred. As well as treating patients in remote areas of the world, and providing supportive measures such as special shoes to avoid recurrent blisters, Lepra also concentrates on the social problems of the disease. For example, it offers micro-loans to unemployed leprosy sufferers so they can Who we are: start up small businesses such as growing and selling fruit Crossing Borders is a national network of students interand vegetables, thus facilitating social reintegration. ested in refugee healthcare issues, which aims to improve the health of asylum seekers and refugees by removing the Lepra’s Work in India barriers to their healthcare. HIV/AIDS makes people more susceptible to contracting leprosy and so much of Lepra’s work in India is focused on What we do: HIV prevention, especially amongst commercial sex Members of the various branches do this through different workers. These workers are often outcast from society in methods. These voluntary projects include practical action India and so their health needs are neglected. Lepra’s such as mentoring refugee doctors; working to get related Healthy Highways project is run by commercial sex workers, health issues onto the medical school curricula; awarenesswho aim to educate their peers on the risks of HIV and on raising of healthcare entitlement to newly-arrived asylum how to prevent infection. The project has been extremely seekers, and helping them to register with GPs; and camsuccessful, as it empowers these otherwise ostracised paigning on government policy. women to make a real difference to their own as well as others’ lives. How to get involved: As yet there is no CB branch at UCL. I am hoping to change Another group of society often marginalised in India are that this year! If you would like to get involved please contact homosexuals. Many of the men I met who are involved in the Mandy Grewal at m.grewal@ucl.ac.uk. Lepra projects live double lives. By day they are “happily” For more information about Crossing Borders see married with children, and by night they meet their male www.crossingborders.org.uk partners in secret. If a sector of society is publicly “invisible”,

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Medsin UCL’s Global Health Magazine

December 2008 - Issue 2

Reviews The Wisdom of Whores By Elizabeth Pisani, Published by Granta Books June 2008, available from amazon.co.uk £8.99 f you are anything like me, when it comes to statistics, being continually bombarded with figure after figure renders these statistics rather meaningless. Unfortunately, this is especially true when it comes to coverage of the HIV epidemic. Few authors, let alone epidemiologists like Elizabeth Pisani, have ever thought to attack this issue head on in such an invigorating, empowering and entertaining way which is testament to the success of The Wisdom of Whores.

schmoozing the press, more time speaking the language that voters and politicians understand.” states Pisani, summing up the philosophy behind her work.

Elizabeth Pisani, possibly the world’s first journalist turned epidemiologist, has become a leading expert in fieldwork surrounding the statistics of HIV and AIDS. She has worked on both sides of the fence regarding the reporting of world health statistics, from a journalistic point of view, as well as in a research position within a professional capacity. This, I believe, enables Pisani to cast a revealing light on the relatively unseen world of the struggle to collect the vital HIV/AIDS statistics we read about on a daily basis. The Wisdom of Whores is particularly enjoyable as it describes the stories behind the statistics and the stories that shape policies (or not, as regrettably the case appears to be). “We could save more lives with good science if we spent less time worrying about publishing the perfect paper and more time lobbying, more time

Pisani has made a real breakthrough in drawing attention to the lives behind the statistics, and the energy, effort and skulduggery required in order to produce this information must be admired. She writes a refreshingly honest account of her life’s research, not skimping on the details of sexually transmitted infections, anal sex, brothels and drug dens. Once you read this book, you will find it impossible not to appreciate the time and effort taken to produce each and every statistic that The book will have you laughing out we are bombarded with. Hopefully this loud at situations so unfortunate that you will believe them to be made up. In will encourage us to take a little more time in analysing the numbers that a chapter entitled ‘The Honesty Box’, Pisani spills the beans on what can go have, sadly, become so easily wrong in the field of acquiring HIV/AIDS overlooked in the HIV/AIDS epidemic. statistics. When you read about how to get a cooler full of blood collected from By Lucy Reeve a gay club and a sack full of used needles (which it is illegal to carry in Jakarta) through a police road block in

the early hours of the morning, without any money as a bribe (I wont give away how this was done), you begin to see the potential difficulty that epidemiologists working with HIV/AIDS face on a daily basis in order to carry out their work. However, that is only the tip of the iceberg. There are further issues that Pisani highlights, such as getting arrested for selling sex on the eve of a political election, which is not the best of ideas in a country riddled with corruption.

An Imperfect Offering By James Orbinski (Past President of Medecins Sans Frontieres) , published by Rider & Co (5 June 2008), available from amazon.co.uk £11.89 “Stories are all we have”. This is the title of the opening chapter of James Orbinski’s memoirs recounting missions as a humanitarian doctor in Somalia, Rwanda, Afghanistan, Zaire and Kosovo. The memoirs allow the reader to discover how Médecins Sans Frontières (MSF) truly operates on the ground. His descriptions give an insight into what led Dr. Orbinski to become a doctor, a committed humanitarian and president of one of the most famous

non-governmental organisations in the world.

His account blends the logistics and negotiation needed as part of a mission, with the odd clinical detail, but After a short introduction on his always with an underlying frustration upbringing in Canada, he focuses on and anger. Anger directed towards his different postings with MSF. The those responsible for the killings and to largest and most impacting chapter is the international community for being on his time in Rwanda during the so slow to react. His frustration lies in ‘genocide’ no one wanted to admit to in his limited capacity to resolve the 1994. It is a powerful and sometimes situation. emotionally draining account of the unimaginable suffering he witnessed.

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December 2008 - Issue 2 This is not a diplomatic or neutrally informative account of different missions he was part of – that is not what MSF is about. It is what he saw, his reactions to the situation, the international community and the organisations they can hide behind. He has no problem pointing an accusatory finger at the French government for their involvement before, during and after the Rwandan conflict. It is easy to become lost in his blow-by-blow account; the reader feels his anguish, despair and determination to keep going. Noticeably, however, he never speaks with any cynicism or hopelessness.

Medsin UCL’s Global Health Magazine fell victim to a land mine by saying; “His leg was in a bucket and he was [still] alive”. Overall, he defines what it is to be a doctor working with a humanitarian agency. Not only improvising all the things you learn at medical school because of limited resources, but also the powers of negotiation needed to ensure the safety of your team and your patients. Furthermore, he reflects on He acknowledges that what MSF how it is impossible to be a provides is “an imperfect offering” in the humanitarian and apolitical, and to have sense that it is limited in what it can do to learn to deal with the politics of a due to the political circumstances in situation without getting involved in which it operates. However, their work them. is necessary and he exemplifies this, after amputating a young boy’s leg that By Elena Ferran

The Medsin National Conference, October 2008

he Medsin National Conference on ‘Power and Politics in Global Health’ was hosted by UCL this year and exemplified why UCL is considered ‘London’s Global University’. The conference was divided into 4 plenaries over two days, each of which was followed by a range of workshops for the 450 delegates who attended from all over the UK. The variety of topics discussed was impressive and all related back to the overall theme, which was more topical than ever in light of the upcoming US elections, the threat of NHS privatisation and the current economic crisis. Amongst the speakers was Professor Colin Leys (Professor of Political Sciences at Queen’s University, Canada) who spoke about the threat of privatisation to the NHS. He explained how changes towards a healthcare market, designed to improve the NHS by introducing competition, has actually increased administration costs and led to duplication of services.

Medsin also used the opportunity to exemplify the disproportionate doctor:patient ratio in developing countries. in a world of limited resources.

Dr Elizabeth Pisani (epidemiologist and author of ‘Wisdom of Whores’ – see review) spoke candidly in the final plenary titled ‘Civil Society’ about the role of non-governmental organisations (NGOs) in development. She gave her views using first hand examples of NGOs applying for funding; however, this turned into a rather cynical debate which stirred the panel of speakers into On the Sunday, Dr Roberto de Vogli a mini-frenzy and epitomised the (Lecturer in Social Epidemiology and passion that those working in the global Global Health at UCL) spoke about health sector necessarily possess. The ‘Globalisation and Social Justice’ and heated debate was cut short by the introduced some alarming facts. closing speech from Clare Short MP Amongst these, he revealed that WalMart generates more money than all of Secretary for International Development 1997-2003 and who resigned over the Sub-Saharan Africa. He ended on a government’s decision on Iraq. She very resonant note, however; linking global warming to the current economic ended the conference on a positive and realistic note; global health inequalities crisis, he described the unrealistic are an enormous problem, but there are nature of mankind’s obsession with permanent, unlimited economic growth solutions.

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On the whole, the level of organisation was outstanding throughout the conference. The initial registration was quick and painless; there was a fantastic world music social on the Saturday evening and the catering included biodegradable lunch boxes and plenty of Fairtrade food by Traidcraft. These were all unexpected bonuses to what was a fascinating, inspiring and enjoyable weekend. It was impressive to see so many students from all over the UK attending, with a high proportion of non-medical students, illustrating the multidisciplinary nature of Global Health. I highly recommend attending the next Medsin conference, to be held in Manchester on the 27th-28th of March 2009. See www.ghc09.org for more information. By Elena Ferran

Medsin UCLâ&#x20AC;&#x2122;s Global Health Magazine

Visual Perspectives

December 2008 - Issue 2 (Left) The economy of China may be booming, but there is still a long way to go before it can strike a balance between economic development and environmental sustainability. Air pollution is one of the most serious health problems in its fast-growing cities; ambient concentrations of total suspended particulates and sulphur dioxide are among the highest in the world. The burning of low-grade coal, which accounts for more than three quarters of its commercial energy needs, is the primary source of Chinaâ&#x20AC;&#x2122;s air pollution. Here, smog obstructs the view across the harbour in a central part of Shanghai. Taken by Melissa Chiu

(Right) This photo depicts the life of children in a rural village in Kenya, where malaria, a disease which causes anaemia in the young, is still endemic. Malaria is more common in rural areas, where there is often a lack of adequate healthcare and sanitary conditions. Furthermore, coinfection with malaria and HIV (which is highly prevalent in Kenya) increases the likelihood of death significantly. Taken by Alisha Allana

(Left) At any one time, half of the world's hospital beds are occupied by patients suffering from water-borne diseases and over 884 million people worldwide use unsafe water sources. Taken by Umar Ahmad

Please send in your photos with a caption to medsinmagazine@gmail.com to be published in the third issue 32

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December 2008 - Issue 2

Medsin UCL’s Global Health Magazine

What’s Going on...

By Maria Bartkiewicz

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

December

January

Missionaries and Their Medicine: A Christian Modernity for Tribal India Tuesday 9th 17.00-18.30 Faber Building, SOAS, Room FG08

The World Food Crisis: Perspectives from the Global South Tuesday 27th – Wednesday 28th 10.00 – 18.00 Brunei Gallery Lecture Theatre, SOAS

David Hardiman (University of Warwick) will run this seminar, part of the South Asia History Series. See http://www.soas.ac.uk/events for details.

Visit www.ucl.ac.uk/globalhealth/events to register and for more details

UCL Institute for Global Health Symposium - Human Rights and Disability: The Missing 10% of World’s Population Wednesday 10th 16.30-18.00 JZ Young Lecture Theatre, Anatomy Building, Gower Street

Humanitarianism at the Risk of Imperialism: The Globalisation Lectures Series Wednesday 28th 18.30-19.30 Brunei Gallery Lecture Theatre, SOAS A lecture by Dr.Rony Brauman, former President of Doctors Without Borders (MSF). This is a public lecture and there is no need to register.

The speakers will include Professor Nora Groce (UCL Epidemiology and Public Health / Leonard Cheshire Disability), Professor Colm O'Cinneide (UCL Laws) and Raymond Lang (Leonard Cheshire Disability).

An Ethical Christmas How can you do your Christmas shopping altruistically this year? The answer is to buy your friends and family an ethical present. Here are some suggestions: Ethical Christmas Fair at Canning House (free entry) Thursday 18th December 16.00 - 20:30 2 Belgrave Square, London, SW1X 8PJ The place to buy your Christmas presents this year! Stalls will include the SONRISA stall, where you can buy beautiful handmade Christmas cards (all proceeds go to charity). People Tree The Fair Trade Fashion pioneers. Visit their website (www.peopletree.co.uk) to check out the latest ethical, yet fashionable, clothing. Divine Chocolate Visit their website (www.divinechocolate.com) or your local supermarket to get your hands on great value Fairtrade advent calendars and many other delicious Christmas gifts.

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Medsin UCL’s Global Health Magazine

December 2008 - Issue 2

Organ Frenzy Link the tropical diseases listed with the body organ that they affect (answers below) 1. Chagas disease: is transmitted to humans via an insect vector known as the ‘blood-sucking assassin’. The disease is exclusive to the Americas, particularly to poor, rural areas within Central and South America. In the chronic phase of the disease, the muscle of one major organ may fall victim to this silent killer. Which organ is it? 2. Schistosomiasis: is caused by a parasitic worm that is transmitted to unsuspecting humans by water snails. The disease is common to Asia and Africa. In order to perpetuate the disease cycle, the worm’s eggs are craftily shed from the human body via the urine. The eggs shimmy through many bodily organs during the maturation process, but which organ does the adult worm migrate to once it has blossomed into its full glory? 3. Opisthorchis Viverrini: is a species of waterborne parasitic worm that is very common in Thailand. The parasite initially attacks the bile ducts in the human, but which organ does it then go on to infect? (Hint: in very severe cases, it may have the same effect on this organ as alcohol.) Answers 1. Heart

2. Bladder

3. Liver

Statistical Suprises Choose which country applies to the data posed in the question to uncover some shocking statistical surprises (answers at bottom of page) 1. Which of these countries spends only 2.1% of its total GDP (Gross Domestic Product) on healthcare? a) Indonesia, b) Iraq c) Gambia 2. In which of these countries does over 70% of the male population smoke? a) Cuba b) China c) Russia 3. In which one of these countries is over 40% of the adult female population anaemic? a) Costa Rica b) Sri Lanka c) Turkey 4. Put these countries in order of average life expectancy, from lowest to highest. Uganda, India, Afghanistan, Namibia, Kazakhstan 5. Which of these countries has the lowest number of births facilitated by a trained health professional, comprising only 13% of all deliveries? a) Anguilla b) Bangladesh c) Chad

Answers 1. a) 2. c) 3. c) 4. Afghanistan (42years), Uganda (49years), Namibia (54years), Kazakhstan (61years) and India (62years) 5. b)

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December 2008 - Issue 2

Medsin UCL’s Global Health Magazine

Do you know these titles from Oxford Journals…? _____________________________ InnovAiT Published on behalf of The Royal College of General Practitioners Executive Editor: Chantal Simon • Publishing since 2008 • 12 issues per year This journal for Associates in Training (AiTs) promotes excellence in primary care and quality education. Rotating through the whole new curriculum for the nMRCGP on a three year cycle, InnovAiT supports and assists the learning and development of AiTs as they progress through training. Each issue covers two clinical themes, and one non-clinical area alongside a news section. It also regularly includes a ‘From the Trainer’ column offering guidance to supplement that provided by the AiT’s real-world trainer, exam tips from a recently qualified GP, and an ‘applied knowledge test’. Visit www.rcgp-innovait.oxfordjournals.org for more information.

________________________ International Journal of Epidemiology Published on behalf of The International Epidemiological Association Co-Editors: G Davey Smith & S Ebrahim ▪ Publishing since 1972 ▪ 6 issues per year The International Journal of Epidemiology is an essential requirement for anyone who needs to keep up to date with epidemiological advances and new developments throughout the world. Its impact factor has been rising steadily over the past few years and is currently 5.151*. The journal is also ranked 7/100 in the category of Public, Environmental, and Occupational Health.* Visit www.ije.oxfordjournals.org to read free articles, sign up for content alerting services, and access the top 50 most highly cited articles. *(source: Journal Citation Reports, published annually as part of the Social Science Citation Index by ISI)

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December 2008 - Issue 2

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