Issue 5 - UCL Medsin Perspectives Magazine by Medsin UCL

Perspectives

UCLU Medsin’s RUMS Society’s Global Health Magazine

Sri Lanka The Civil War

Maternal Health

Millennium Development Goals

Gender Equity What can we learn?

Published on behalf of UCLU Medsin RUMS by Zaneta Forson & Efuntunde Akerele

Perspectives

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Letter from the Editor Haiti, but before the earthquake, Haiti was a country struggling and crippled by a history of instability. Yes, these problems are exacerbated by the earthquake, and unfortunately bring a whole host of basic problems such as poor sanitation that will lead to increased spread of disease, poor health, poor transport access and the potential increase in crime and violence due to the frustration of the thousands of displaced Haitians. The aftershock trauma that evistability for the already vulnerable Haitians. The increased awareness that come with all the media attention and with aid now being poured into the Haiti, this could be an opportunity, hope and anticipation that Haiti will be rebuild and the many disillusioned Haitians can hope for a better future for themselves and their country. Awareness and education often are instrumental in tackling many of the health problems that plague our world. So this issue we discuss this often neglected areas of Global Health and attempt to understand why they have been forgotten and what is being done to better the situation. With the earthquake leaving 100,000 people dead in Haiti, the psychological effects of such loss of life will invariably leave a severe mark in the survivors of Haiti. With this in mind, Alisha Allana focuses on Mental illness, an issue that is often forgotten when discussing global health issues. The fallouts of deprivation present the dangers of counterfeit drugs, illegal drug use and the consequences therein. Annabel Sowemimo covers this issue in her article “Do you want the real or the fake one?” In this issue of Perspectives, we bring you a wide range of topics, from the Women’s Health section to the rise of incommunicable diseases as addressed by Martin Everson in his article Diabetes in developing countries. We also have some fantastic reviews on events organised by UCL Medsin and externally as well as a fully packed calendar to keep you busy in the coming months. I hope that after reading this issue of Perspectives, Global Health won’t be two seemingly vague words, but will mean something to you. Enjoy Adaugo J Amajuoyi Chief Editor

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Contents 4

Current Affairs

Chagas Disease

Do You Want the Real One or the Fake One?

Diabetes

Forgotten and Fatal

The Fight Against Cervical Cancer

Maternal Health

Gender Equity

Rethinking Mental Illness

After the Tigers

A Hungry World

No-one Gets Cleft Behind

Save the Humans

The Art of Campaigning

Event Reviews

Reviews

10 Facts and Figures

Calendar

Cover photo from: www.msf-speakup.com/ blog/wp-content/uploads/2009/04/rtxeapg_ main_picture3.jpg

February Issue 5

The Team Chief Editor Core Editors Head Designer Proof Readers Webmaster

Adaugo (Diggi) Amajuoyi Lucy Reeve Katherine Pitt Katherine Law Alisha Allana Chibuzo Mowete Folasade Adu Yemi Bello Joel Cunningham

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Current Affairs Earthquake in Haiti

major earthquake of magnitude 7.0 has struck Haiti on 12 Jan, just tens miles from the capital Port-au-Prince - the most densely populated region in the country with some of the largest slums in the world. The earthquake has left 100,000 people dead in 10 seconds, and according to the European Union, officials estimate the death toll to have reached 200,000. Schools, hospitals, the presidential palace and the UN mission in the capital Port-au-Prince are among the buildings destroyed, and the destruction is aggravated by the poor urban planning and construction standards in the poorest country of the western hemisphere. Thousands are still trapped among the ruins, and desperate search for survivors are still going on amidst the aftershocks.

Haiti is situated next to Cuba and Dominican Republic in the west Caribbean sea. It was the first nation after the US to gain its independence from European colonialism in 1804, and it was the first sovereign black nation in a region still blighted with slavery, yet, it remains the poorest country of the western hemisphere with 80% of Haitian living under the poverty line (less than USD$1 a day) and relies on foreign aid and UN peacekeeping operation to maintain some degree of social stability. The country is already a humanitarian disaster before the earthquake sets in - the population of 9 million has barely recovered from a series of devastating flash floods, hurricanes and mudslides in the last few years. As the impact of the catastrophe sinks in, the lack of food and water is contributing to tension in the city. Since the control tower of the airport is destroyed, the supplies of food, water and medicines are still sitting on the runway at Port-au-Prince airport unable to move. Dead bodies and wounded patients are still among the streets and collapsed slums, as most of the medical centres and hospitals are not functioning. The problem of security is also emerging, exacerbated by anger at the apparently slow pace of the relief effort. “There have been

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incidents of people looting or fighting for food. They are desperate, they have been three days without food or any assistance,” the UN peacekeeping chief, Alain Le Roy, said. With aid still slow to actually come in, no authority in Haiti, and with the capital city shattered, lawlessness, a lack of clean water, and diseases could kill many more in the weeks and months ahead. Currently, aid agencies and the US military are engaged in a desperate race to provide Haitians with clean water to stave off the threat of dehydration and massive outbreaks of waterborne diseases, yet the Haitians will need more than the shortterm aid - the long-term support from all countries will be vital to determine the stricken state’s future and to heal Haitians from years of poverty, political crisis, natural disasters and international neglect. Katherine Law Second Year Medical Student

Swine Flu Update The swine flu virus has not caused the numbers of cases nor fatalities expected in the early stages of the pandemic, and the authorities are scaling down their anticipation of a rampant pandemic. The weekly government briefings have stopped, and replaced by a fortnightly bulletin with statistical trends for the sake of interested journalists. 360 people in the UK have died as a result of swine flu, and most of them had underlying health problems; now, less than 5,000 cases a week are reported, almost half the level of even a month ago. The initial panic and estimates of 65,000 deaths in the UK alone led the government to plan a large-scale vaccination scheme, and in May 2009 Britain ordered 60 million vaccines from the pharmaceutical company GSK. The absence of a ‘third wave’ of cases, and the sufficiency of just one dose to immunise patients, rather than two, has prompted the government to modify its contracts for the vaccines. Other European countries including Germany, France, Spain and Belgium are also in talks with GSK to cut their orders, which is expected to make a loss of up to £300 million. The over-estimated mortality predictions suggest that the public, the media, and politicians succumbed to the hype of a health scare, and over-reacted by spending £1 billion on vaccines, most of which are now unwanted. Joshua Balkin Third Year Human Sciences Student

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OSIS!

Chagas Disease:

DIAGNO

Breaking the Silence

hagas disease is responsible for more deaths in Latin America than any other parasite-borne disease, including Malaria 1. A silent killer, Chagas disease has a long asymptomatic phase, affects poor rural communities with no voice, and receives scant public recognition or funding. 2009 marked the centenary of the disease’s discovery, and the launch of an international campaign to fight it2. Geographical distribution and impact Chagas disease is endemic in 21 countries in Latin America3. In this region, an estimated 18 per cent of the population are at risk, amounting to 100 million people. Every year, more than 8 million people contract Chagas disease, and 14 000 people die. The resulting cost in disability-adjusted life years (DALYs) is estimated at 667 000. The economic consequence is severe. In Brazil, the lost wages and industrial productivity is estimated to be US$ 1.3 billion1. Global immigration is broadening the parasite’s distribution; incidence-rates are increasing in America, Australia, Canada, Japan and Spain3. Transmission Chagas disease, or American Trypanosomiasis, is caused by the kinetoplastid protozoan parasite Trypanosoma cruzi3. 80 per cent of cases are spread by large, blood-sucking reduviid insects, known as ‘kissing bugs’. These vectors occupy the thatched roofs and cracked walls of adobe houses occupied by Latin America’s poor4. 15 per cent of cases are transmitted by blood transfusions or organ transplants, 4 per cent by congenital (mother-to-child) transmission, and less than 1 per cent by other causes1. Congenital transmission, while respon-

sible for a small proportion of cases, is significant in absolute terms. In Latin America, 1,809,507 women of childbearing age (15 to 44) are estimated to be infected with Chagas disease, and mother-to-child transmission occurs in 12 per cent of births1. Public health campaigns have focused on limiting vector transmission rather than treating existing cases4. This approach is deficient, both in neglecting the moral imperative to treat current patients, and in failing to prevent congenital transmission. Natural history Chagas disease has two distinct clinical stages. The initial acute stage follows parasite entry and invasion of the bloodstream. This stage is characterised by fever, malaise, facial oedema, generalised lymphadenopathy, and hepatosplenomegaly3. While this phase generally resolves in four to six weeks, it kills 5 per cent of affected children1. The subsequent chronic stage is divided into an asymptomatic ‘indeterminate’ phase and a symptomatic phase. Patients in the asymptomatic ‘indeterminate’ phase transmit the parasite but display no symptoms. This phase may last for ten years5. Up to 30 per cent of patients progress to a symptomatic phase with chronic complications3. The most common, and frequently fatal, pathologies are gastrointestinal (megaoesophagus and megacolon) and cardiac (cardiomyopathy)5. Chagas disease is the leading cause of infectious cardiomyopathy worldwide1.

CHAGAS Current treatment

A E R T ! S I T S O N G N A I D ! E S I S O N M G A I D T ! S I S A E IAGNO R T ! T N E M T A E TR

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The two drugs used to treat Chagas disease, Nifurtimox and Benznidazole,

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IAGN

were developed over 40 years ago, and production is limited to Brazil4. Their efficacy is limited, curing only 10 to 20 per cent of cases in the chronic phase 1. Trypanosoma cruzi is developing resistance, causing regional variations in treatment effectiveness. The side-effects are debilitating, and undermine patient compliance; nifurtimox can cause digestive disturbances, including abdominal pain, nausea, and anorexia, and benznidazole can cause haematological disorders and hypersensitive dermatitis3. The treatment duration is long, at 30 to 90 days, and resource intensive, necessitating specialised medical supervision. Despite significant child mortality, no paediatric strengths of the treatment exist. Despite widespread congenital transmission, the treatment is contraindicated in pregnancy3.

Drugs for Neglected Diseases initiative Chagas disease is a dire example of a wider imbalance; just 10 per cent of research money is spent on diseases causing 90 per cent of the world’s health burden6. In 2007, Chagas disease received 0.4 per cent of spending on neglected diseases research4. MSF devoted its 1999 Nobel Peace Prize funds to addressing such inequities, and launched the Drugs for Neglected Diseases initiative (DNDi). DNDi is a collaborative, not-for-profit, research and development organisation. In 2009 DNDi launched an international campaign to raise awareness of, and increase research into, Chagas disease. The latter has two primary aims: a safe and effective paediatric treatment, and a new drug for the chronic stage of the disease1. Chagas disease is a silent killer. Latin America’s rural poor lack the political power and market value to attract the attention of pharmaceutical companies. DNDi, and its international campaign against Chagas disease, offers an opportunity to redress years of neglect. However, its success depends on public support. For further information: Visit: http://www.treatchagas.org/ Visit: http://www.chagas-break-thesilence.com/ Join Friends of MSF (http://www.msf. org.uk/ucl.friend, email: uclmsf@ googlemail.com) Katherine Pitt Second Year Medical Student

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“Do you want the real one or iiithe fake one?” Counterfeit Medicine, a global menace

‘

o you want the real one or the fake one?’ This does not sound like a question you would typically associate with your local pharmacy, yet in many countries this and similar questions are fast becoming a reality. The production of counterfeit drugs is increasingly becoming a global issue with its high risks and at times horrifying consequences. After, several recent scandals and the increasing relevance of counterfeit drugs as over the internet drug purchasing booms many governments are starting to take action against the ruthless players in the potentially fatal counterfeit drug roulette.

The WHO definition of a counterfeit drug: “A counterfeit drug is a drug that has been deliberately and fraudulently been mislabelled with respect to identity and/or source. Counterfeiting can apply to both branded and generic products and…may include products with the correct ingredients or with the wrong ingredients, without active ingredients, with insufficient active ingredients or with fake packaging.” 1 Although, there is also overlap between counterfeit drugs and those that are described as substandard, which ultimately can be equally as harmful due to them containing the inappropriate ratio of ingredients or old ingredients. And for those who fall victim... WHO has estimated the most severely impacted countries with respect to counterfeit drug production as being Lebanon which ranks the most highly with 35% of drugs distributed thought to be counterfeit followed closely by Kenya, Indonesia and India 2. Nigeria which ranks sixth2 most highly on WHO’s list of countries most affected by counterfeit drugs was struck by scandal in 2008, when the government reported that 84 babies3 and young children had died after ingesting pain relieving syrup containing a chemical normally found in antifreeze. Many of them suffered horrendously from fever, convulsions, diarrhoea and vomiting after taking the syrup, My Pikin Baby Teething Mixture, that was suppose to relieve teething pain. The anguish and horror associated with such an incident reverberated around globally, forcing the Nigerian government and other countries to tackle the issue of counterfeit medicine. It has also been demonstrated that counterfeit

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World Health Organisation Poster Campaign

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medicine is also a problem within the UK, in 2007 the discovery of Zyprexa4 that was distributed (a drug used in the treatment of schizophrenia) without sufficient active ingredient within the UK showed that the effects of counterfeit drugs can span far and wide. In such a case it proved difficult to determine who and how many were affected by the drugs distribution, as not everyone who has been exposed to the drug can always be contacted and the psychological and emotional repercussions for individuals and families are often immeasurable. An International Threat Furthermore, counterfeit medicine is becoming increasingly more important as over the internet drug buying continues to thrive. In an age, where many

people are using the internet for selfdiagnosis some people have started to take it a step further and started to selfprescribe, leading to a boom in illegal internet drug sales. WHO have estimated that in over 50% of cases4, medicines that have been brought over the internet from sites that do not reveal their physical address have been found to be counterfeit. Not only are these companies distributing substandard products but the necessary pharmaceutical advice is often lacking or non-existent, which further amplifies the problem. The Medicines and Healthcare products Regulatory Agency (MHRA) is the branch of the Department of Health that is responsible for regulating medicines within the UK. This January the MHRA made a press release about their concerns over the increasing internet purchasing of

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www.uclmedsin.org counterfeit versions of the weight loss drug, Alli5. In an effort to crackdown they have issued a list of ways in which counterfeit and genuine drugs may be distinguished, but whether this will be enough to overcome increasingly accurate imitations is yet to be seen.

COUNTRY/ REGION

WHO IMPACT ESTIMATE

United States Europe United Kingdom Russia CIS China Indonesia India Nigeria Kenya Lebanon Cambodia

<1% <1% <1% 10% 20% 8% 25% 20% 16% 30% 35% 13%

In order, to fight the counterfeit drug menace a wide range of professionals and international governments must be engaged as to prevent the production of counterfeits drugs before they fall into unsuspecting hands. As to combat the problem of poor regulation in developing parts of the world, WHO has published guidelines to help implement safer controls as well implement harsher penalties for those caught partaking in drug trafficking. It highlights the importance of strengthening political will and commitment to the cause, enforcing drug control laws, sharing responsibilities and setting up an international body for the regulation of counterfeit drugs. In 2006, WHO created International Medical Products Anti-Counterfeiting Taskforce (IMPACT) 5, which promotes a collaborative effort between the global community to raise awareness of the dangers that counterfeit drugs can bring.

exportation through free trade zones, thus in countries where many face economic hardship a strong incentive must be provided as a deterrent4. Also, the ignorance of workers at the lower levels of the supply chain should also not be underestimated, and WHO has been attempting to combat this ignorance as a method of ceasing the production of counterfeit medication.

The issues that lie beneath

Moving Forward

However, the impact that better regulations and harsher punishments can have are limited unless the root causes of counterfeit medicine is tackled. In developing countries, people’s desire for cheaper and more easily accessible medicine is undeniably an important factor. It is no secret that the price of some drugs can equate to a sizeable sum of a family’s income, and in an effort to prioritise many people choose to ‘compromise’ and buy the ‘fake’ version of a drug. In some cases such as antimalarial drugs high demand also means higher prices, making cheaper counterfeit drugs ever more enticing. Furthermore, poverty often means that many individuals cannot access a doctor, often leading to desperation and ignorance about the possible effects of counterfeit medication. Accessibility is even more problematic in more rural parts of developing countries, where health facilities are more likely to be scarce4. If an individual is poorly they are more likely to settle for whatever medication is immediately available, often this medication is substandard.

In conclusion, it can be seen that counterfeit medicine is a multi-faceted problem that is affecting the lives of individuals global as well as impacting upon the life of someone, right here and now in the UK. It is not a problem that can be

But poverty can also play an important issue in the production of counterfeit medicines, key countries such as China which has a large divide between the rich and the poor being responsible for a high proportion of counterfeit drug production. Counterfeit drug production can be highly lucrative through the

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easily overcome by tougher penalties or more legislation, but requires the input of the international community to help educate people about the repercussions of counterfeit medicine as to ensure that people only have access to what they deserve – ‘the real one’ and to ensure that faith in the health care system is not undermined. For information and ways to help combat counterfeit medicine check out: http://www.who.int/impact/activities/ en/ Annabel Sowemimo Second Year Medical student

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Diabetes

The Silent Killer

alaria. Tuberculosis. HIV. Most of these names are usually recognised as infectious diseases which put huge strain on the populations and ‘health systems of developing nations. Now a new, non infectious but no less costly threat is emerging – Diabetes. This disease is a silent killer in the truest sense, receiving little attention from global media or health planners in comparison to other diseases traditionally associated with the developing world. The disease is now implicated in as many deaths per year as HIV/AIDS1 and can cause complications which devastate individual lives and have a massive impact on health systems of rich and poor countries alike. Diabetes is responsible for 5% of deaths worldwide each year2, roughly 3.8million or the equivalent of one person every ten seconds1. Even more staggering is that of all those worldwide with diabetes, traditionally believed to be a condition of industrialised nations and lifestyles , 80% live in low or middle income countries2. Perhaps most alarming is the rate at which the spread of diabetes through the nations of the third world is forecast to take place during the next twenty years. Diabetes is a condition which presents during childhood (type I) or during adult life (type II). It occurs as a result of our bodies either not producing or being insensitive to the hormone Insulin. Usually after a meal the level of sugar, or glucose, in our blood increases. Insulin is then released into our blood causing our liver and muscles to take up and store this extra glucose for when we need it. In the case of diabetics, this process does not occur; instead their tissues do not take up glucose so it remains in the blood in unusually high amounts.

Diabetes is non-infectious and generally associated with the overindulgences of life in the developed world – diets rich in fats and sedentary lifestyles, which can lead to obesity, high blood pressure and cholesterol – all of which are risk factors associated with diabetes. Until recent years the risk factors for this condition were not seen in the populations of the developing world. As nations have continued to develop with gradual industrialisation and adoption of western lifestyles, so the prevalence of diabetes within the global population has increased. However it is poorer nations, who lack the healthcare infrastructure, screening programs, funding and knowledge of diabetes prevention who will be particularly burdened as numbers with the disease continues to increase. At an individual level, the complications of diabetes are devastating. Chronically high blood sugar can lead to damage and blocking of the body’s smaller blood vessels, these vessels are typically found in the hands, legs and feet.– The blood vessels in the eyes are also affected – a leading cause of blindness.. When these arteries become damaged, not enough blood gets to the extremities - a condition known as peripheral vascular disease. This means that the tissues which do not get enough blood take longer to heal when injured. A small cut, once infection sets in, can develop so seriously that an amputation may be required due to gangrene and blood poisoning. Such consequences of diabetes are a problem even in the western world where sanitation is relatively good and medical care prompt and thorough. In developing countries sanitation is poor, so such infection is more likely to occur and once it does the access to proper medical care is often so substandard that is can

be fatal. The economic cost to the poorer nations of the world is difficult to estimate for a number of reasons. Diabetes itself is not usually a killer, but the complications which can arise from it most certainly are. Such complications as mentioned above include atherosclerosis, strokes, kidney damage and blindness. These conditions require expensive drugs, possibly with surgery and long term management – difficult enough even in wealthy countries with widespread and well funded health systems. In developed countries screening for the long term complications of diabetes is much more organised than in poor nations for a number of reasons, including cost, personnel and infrastructure. This means that many of the expensive interventions listed above, required for the complications of diabetes are not obtained until much further in the course of the disease. As a result most people who have the condition live normal and full lives. In developing nations these complications arise much earlier because the symptoms of diabetes are poorly recognised and so it goes uncontrolled. The WHO states that most people with diabetes in the third world are in fact middle aged2. Not only are these people, at least those that can access healthcare, costing health systems money to treat, , their countries economic productivity is reduced further. The global impact of the diabetes epidemic has only gradually been recognised in recent years. In the third world, a closer focus is often placed on infectious diseases typically associated with developing countries. This has meant that diabetes is has passed relatively unnoticed or overlooked as a massive

Figure 1: International Diabetes Federation Expected increase in diabetes prevalence

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www.uclmedsin.org Figure 2: adapted from WHO Diabetes programme statistics: prevalence of diabetes by region

World region

2000

2030

World Africa Eastern Mediterranean Americas Europe S.E. Asia Western Pacific

171,000,000 7,020,000 15,188,000 33,016,000 33,332,000 46,903,000 35,771,000

366,000,000 18,234,000 42,600,000 66,812,000 47,973,000 119,541,000 71,050,100

health problem for the future. Furthermore, since the late 1980’s large numbers of studies have been conducted to look at the distribution and effects of diabetes on worldwide populations and health systems. However these studies were difficult to analyse and countries lacked guidance from a central organisation on the potential impact of diabetes on their populations, as well as ways to reduce its health burden. This led to the WHO setting up its Diabetes Programme. The aim of the WHO Diabetes Programme (WHODP) is to collate information, studies and statistics on the individual, socioeconomic and health problems caused by diabetes. It also aims to raise awareness of the real threat that diabetes poses to developing health systems and nations now and in the future. As with many diseases affecting the third world, it is very easy to be lured into thinking that they affect mainly Africa, since this is where most media attention falls. Diabetes is a condition with a truly global impact, almost every world region; the Americas, Asia, India and Europe. The WHODP’s research into the spread of the

diabetes epidemic over the next twenty years makes for grim reading. The expected explosion within the next twenty years of the diabetes epidemic worldwide of grave concern. Along with third world nations experiencing huge rises in the prevalence of diabetes, indigenous populations, who in some cases are genetically predisposed to diabetes, will also be severely affected. In (fig 1) we see can see the areas where the population with diabetes is expected to rise by up to 120% in black and grey – a grim prognosis. Similarly shocking are the sheer numbers of people expected globally to have diabetes by 2030. As (fig 2) illustrates the number affected across the world is expected to increase from 171,000,000 in the year 2000 up to 366,000,000 in the year 20304. A closer look at these figures shows us just how much this increase will be seen across developing nations: 71,050,100 Fortunately the WHO believes that as part of its Diabetes Programme, along with help from the International Dia-

betes Foundation (IDF), the UN and the concerted effort of its member nations’ governments, this predicted situation can be avoided. While the incidence of diabetes will almost inevitably increase as a by-product of development across the world, we can hope that it will not spread in such a rate that the health systems of developing nations, already groaning under the strain, will not be pitched into crisis. It aims to do this firstly by raising global awareness of diabetes as a serious disease; an example of this would be the annual world diabetes day on November 14th. Secondly in combination with governments across the world it is trying to improve screening and diagnosis of diabetes early, to prevent the personal and economic consequences of uncontrolled diabetes occurring. Perhaps most importantly, with diabetes being preventable in a lot of cases, it aims to educate populations about ways of reducing the risk of diabetes and its complications developing in the first place. These include a healthy balanced diet, regular exercise and reducing smoking. Hopefully the diabetes epidemic will turn out to be an example where a global health crisis was avoided by good planning, collaboration between governments and NGOS, under the leadership of the WHO and IDF. If the condition is not taken seriously, as the figures show, the financial and human cost of diabetes will be one of the defining failures of global health promotion in this century. Martin Everson Second Year Medical Student

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Rheumatic Heart Disease in Developing Countries bling condition could indirectly hinder the productivity of the country and slow down economic development. Thing of the past RHD was a major problem for the industrialised nations in the Mid-twentieth century. Cararpetis explained that children with RF filled the Paediatric wards at the time. Coincidently the vast number of papers published on the topic of RF at the time exceeded other urgent issues like Stroke and other cardiovascular disorders2. However towards the later part of the last century, the prevalence of RF receded and with that, the amount of research on the disease also decreased.

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Unfortunately RHD is still major problem for developing nations whose health systems are already stretched with the demands of infectious diseases like HIV, Malaria, Tuberculosis. The decline in interest and research in RHD will only further hinder awareness to the growing problem of RHD. But why does RHD once a disease of the both the industrialised world and the developing still affect the developing countries. The answer is that RHD is a disease of the poor.

t is a commonly known fact that conditions like HIV, Malaria and Tuberculosis claim the lives of millions of people around the world with the majority of that population living in developing countries in Africa and Asia. While these problems dominate the media it is rare to find similar kind of attention drawn to the serious issue of Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD). RHD is still a major cause of morbidity and is the most common form of acquired cardiovascular disease in children 3.It accounts for 60% of all heart disease in children and young adults.10 There are 15.6 million people with RHD and 470,000 new cases of Rheumatic Fever reported each year2. There are 350,000 deaths each year attributed to RHD/RF.12 Whatâ&#x20AC;&#x2122;s more is that these figures may not truly reflect the overwhelming burden of RF, as the statistics on these figures are often unavailable. RHD is an autoimmune disease that starts off with a common throat infection caused by group A streptococcal bacte-

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ria (GAS).The antigens on the surface of the bacteria provoke an abnormal immune reaction that triggers the production of cytokines and antibodies aimed to prime streptococcal carbohydrates and myosin (a component of heart tissue) to be destroyed by the individuals immune system. This immune reaction, Rheumatic fever, damages and weakens the heart valves. The individual may appear healthy but further streptococcal infections can result in further damage of the heart valves. Poor living conditions, overcrowding and poor access to health care means that re-infection with GAS is inevitable. The condition develops insidiously until the damage to the heart valves becomes far too extensive before the problem is detected. At this point the child requires heart surgery which is unlikely to be available and if so very expensive. Cost is not the only unfortunate result of RHD. In developing countries ravaged by the disease, the majority of the workforce are young adults. This disa-

In the latter half of the last century, wealthy nations like the UK, increased availability and widespread use of antibiotics like Penicillin for treatment of acute pharyngitis has helped significantly to prevent repeated infections of the bacteria and the development of Rheumatic Fever. In addition the standard of living has improved since the first half of the 20th century when RF and RHD was a major concern. Better living conditions and improved quality of hygiene contributed to the reduction in the transmission of bacteria including group A streptococcal bacteria involved in pathogenesis of Rheumatic Fever. Since the 1950s, these improvements including better access to medical services and awareness of the condition, Rheumatic Fever and RHD is rarely diagnosed in children of most industrialized countries. Similar improvements cannot be said of developing nations. There is still a high incidence and prevalence of RF and RHD in non-industrialised nations as well as the indigenous populations of countries like Australia and New Zealand. In the WHO report on RF and RHD, the annual incidence of RF in developed countries is now 1.0 per 100,000. However, incidence rates in French Polynesia was recorded to be 72.2 per 100,000 while that

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www.uclmedsin.org in Sudan was 100 per 100,000. Unfortunately similar figures where found for most African and South Asian countries. The report also showed that the prevalence of RHD of school aged children also varies widely from 0.2 per 1000 in Havana Cuba to 77.8 per 1000 in Samoa. These figures support the concept that persisting prevalence of RF and RHD are strongly influenced by the socioeconomic and environmental factors. Barriers to eradicating RF and RHD There are several problems that contribute to the high incidence of RF and RHD in developing countries. These include the following:• Poor living conditions and poor hygiene and under nutrition. • Overcrowding, which leads to increased transmission and increased risk of the development of RF from the streptococcal throat infections contributes to the virulence of strep strains • Limited or no access to health care • Poor availability of antibiotics and poor adherence to secondary prophylaxis. • A shortage of Resources for providing quality health care • Inadequate expertise of Health care providers • Low level awareness of the disease in the community and by health care providers. • Shortage of an anti-streptococcal vaccine These problems are common to most if not all developing countries and hinder the elimination of RF and RHD. Limited and in most cases no access to quality healthcare is a major obstacle in the primary prevention of RF which involves detection of the sore throat infection. Although this has been proved successful in well supported settings, it is impractical partly due to the nature of the disease, the low level of awareness and in part due to the strain put on health care systems by other disease such as HIV infection and Malaria. Poor availability of Antibiotics like Penicillin makes it difficult to achieve the secondary measure of preventing the development of RHD. Children with RF are recommended to be given monthly penicillin injections to prevent further damage of the heart valves. However such recommendations are difficult to be sustained in the long term. Developing countries are not the only nations are struggling to deal with RF and RHD. The indigenous populations of countries like Australia, New Zealand and Hawaii have some of the highest incidence of RF and RHD while the disease appears to be eradicated in the non-in-

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digenous population. The Aboriginals in the Northern Territory of Australia have the highest documented incidence of RF in the world, 305 cases per 100,000 per year and up to 650 cases per 100,000 per year in remote regions. In addition the standard death rate for RF/RHD is 30.2 per 100,000, 30 times the death rate for non-aboriginals in Australia. The reasons for the high incidence of RF and RHD among the indigenous communities are similar to those in developing countries but also include the following:• Lack of access and trust in the health services • Population mobility – makes it difficult to keep a register of those with RF • Language differences • The availability of water for washing is a problem • Educational limits These additional factors only exacerbate and facilitate the spread and development of RF and RHD among the indigenous communities of industrialised countries like Australia. What needs to be done RF and RHD present its self as a significant cost to both the individual and to health services of the community. In some countries in the Pacific, 15% of their total health budget is spent on sending children with RHD abroad for surgery. Such high costs could have been easily avoided by increasing awareness of the RF and RHD to communities and improving access of antibiotics. As catching RF early on is crucial for the prognosis, diagnosis must be improved. This will involve improving the expertise of health care professionals and also involving more sensitive equipment during diagnosis, such as echocardiography. A systematic review by Marijion et al 2007 involving children in both Cambodia and Mozambique, indicated that echocardiography screening detected a significantly greater number of children with RHD than the clinical diagnosis alone.1 Although expensive, this start-up cost would be nothing in comparison to the future costs of heart valve repair surgery. Losing out on the use of echocardiographic screening would miss out on a significant proportion of children with RF and leave them at risk of severely disabling heart conditions and increased risk of morbidity. In addition the recent availability of high quality portable ultrasound equipment1 makes it possible to screen large number of children at a time, a desirable feature to facilitate health care planning. Increased awareness of RF and RHD among the community and health care workers is crucial to elimination of the disease. There was marked decline in RF

and RHD in Cuba between 1986 and 1996 as discussed by Nordet and colleagues. The findings suggested that prevention and control of RF/RHD is feasible and affordable in developing countries and involved training of health care personnel, posters and educational material for the population, and working with teaching institutions and policy makers to gain their support in targeting those susceptible to RF, school children.11 The study show that the prevalence of RF and RHD fell from 2.27 patients per 1000 children in 1986 to 0.24 per 1000 in 1996. In addition the implementation of the programmed did not incur much additional cost for the healthcare system. Such encouraging results are inspiring and give a good example to other countries what can be achieved. Cuba however has many luxuries other developing countries can dream of. There is a well structured health system with free and easy access to medical treatment for the whole population; the same cannot be said for the majority of developing countries struggling to meet the basic health care needs of their population. There are organisations that are committed to helping eradicate RHD such as RHDnet, part of the World Heart Federation. They provide resources for health professionals including best practice tools - sample databases, management, guidelines, and staff training resources as well as links to other programme resources8. Action is being taken, The Pan Africa Society for Cardiology (PASCAR) in partnership with the World Health Federation started a project to achieve the following:1. Increased awareness of RF/RHD among the Public and Health Professionals 2. Establish surveillance systems 3. Advocate for increased resources for treatment in African nations With such measures in place, it is hoped that this preventable disease will be eliminated left in the past. There is an old Igbo lamentation that begins with the singer asking God for help saying ‘I am at your feet God, for there are so many in your hands, don’t forget to look at your feet.’ Although Rheumatic Heart disease may not be in the limelight, it is such a tragic and disabling condition, the true tragedy would be if such an easily treatable condition goes unnoticed and forgotten. Adaugo Amajuoyi Perspectives Chief Editor

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The Fight Against Cervical Cancer in Developing Countries

n January, British scientists announced that a simple â&#x20AC;&#x2DC;see and treatâ&#x20AC;&#x2122; approach of visual inspection with acetic acid (VIA) could decrease cervical cancer mortality by 100,000 in developing countries1. Cervical cancer is the twelfth most common cancer in women in developed countries such as the U.K. Sadly, one third of women with cervical cancer does not survive within five years 2. However it is important to remember that cervical cancer is in fact preventable if detected in the early stages. The introduction of screening programmes about fifty years ago has led to the decrease in cervical cancer incidence and mortality due to the detection of precancerous lesions which may lead to cervical cancer. However in developing countries, where screening programmes are not accessible, cervical cancer remains the leading cause among cancer death 3. In 2001, The World Health Organisation (WHO) called for a consultation of the problem that developing countries face with cervical cancers4. The report highlights the importance of screening programmes by comparing epidemiology of lowincome and middle-income developing countries. In middle-income countries, where the country is becoming more industrialised and screening programmes are more accessible, the incidence of cervical cancer decreases in a similar way to developed countries. Clearly low-income developing countries are lacking the screening programmes and necessary resources to prevent cervical cancer.

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There is no doubt that cervical screening has its benefits. Screening a woman just once between the ages of 35 and 40 reduces their lifetime risk by 25% to 35% 4 . A positive result in the screening test provides opportunities to fight the disease in the early stages. A woman showing an abnormality in the cervical cells can be referred to a specialist and the necessary treatments carried out. Despite this, there are many barriers that need to be overcome before screening programmes can be fully accessible to women in developing countries. Obviously a major barrier is the cost of screening and vaccines. In the U.S, a single vaccine against human papillomavirus (HPV) costs $300 dollars which is not financially possible for developing countries6. In order for a screening programme to function properly, a host of health professionals are needed such as pathologists to study abnormal cervical cells, specialists to carry out treatments and nurses to provide care and health education. However, it is not simply financial matters that stand in the way. Many developing countries do not quite have the political backing which is needed to fully control cancer. There is also poor infrastructure in their health service which makes the screening programmes less effective as the referral system is not as smooth and speedy. Any screening programme that is in place does not particularly place emphasis on educating women that a negative result does not imply they are not at risk and a positive result does not mean they will develop

cervical cancer. It now seems that these barriers may be things of the past. British scientists have claimed that VIA is a satisfactory screening test which involves lining the cervix with acetic acid (vinegar). VIA has its advantages especially in low-resource settings as it is simple to administer, nurses can be trained easily and the results are available quickly. With the right training, a nurse can treat abnormalities by cryotherapy where they destroy tissue by freezing or loop electrosurgical excision where a thin heated wire removes the abnormal cells. VIA is definitely a more cost-effective alternative for developing countries as it only costs $2 as compared to the $9 cervical lab test conducted in the U.S. Since 80% of cervical cancer cases are in developing countries, VIA is the best screening test to cover the whole target population of women between the ages of 35 and 65. With such a cost-effective screening test it is possible to cover a large proportion of the target group. It is hoped that the barriers will no longer be obstacles to establishing a proper screening programme and cervical cancer incidence and mortality rates will decrease over time. For more information: Cervical cancer screening in developing countries: report of a WHO consultation Emilie Thao Le Second Year Psychology Student

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Maternal Health

Can we meet the Millenium Development Goal by 2015? ever have I been more inspired to think about maternal health. Within the last year two friends of mine became the proud mothers of two bouncing baby girls and a number of other acquaintances and friends are in different stages of their journey towards motherhood. Obviously living in a resource-rich country as the UK they had access to the best that medical care can offer. Both women had excellent antenatal care, meeting their physical and psychological health needs, their babies were born free of serious disease or disability and the birth was directed by skilled midwives and/or physicians in a clean, aseptic environment. All these are known to be essential ingredients to a healthy delivery for mother and child. But it breaks my heart to contemplate that many women across the world are denied such basic rights in a world of iphones and Nintendo Wiis. Let us pause for a moment and assess the current state of maternal health worldwide and recognise the reasons behind the drive to improve maternal health on a global level. What is maternal Health? The WHO defines maternal health as “the health of women during pregnancy, childbirth and the post partum period”.1 The most common direct causes of maternal morbidity and mortality include haemorrhage (large volume bleeding), infection, high blood pressure, unsafe abortion and obstructed labour.1 There are also indirect causes of maternal morbidity such as malaria, anaemia and HIV/AIDS which can complicate pregnancy or are aggravated by it2. Why is good maternal health so important? Good maternal health is obviously very important for the wellbeing of an individual mother but there are also positive ramifications for society as well. Mothers play a very important role in the economy of their families and communities3. An estimated $15.5 billion is lost in potential productivity when mothers and newborns die3. In addition her infant and other children’s survival is seriously threatened and they are more likely to die in the preceding years than children whose mothers are alive3. Maternal mortality has long-term implications on a child’s education, care and health3. When a mother dies a child is more likely to be delayed in starting primary education and suffer from malnutrition and stunted growth and less likely to be im-

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munized3. How can we improve maternal health? The main factors that have been shown to improve maternal health include low cost/technology interventions such as effective family planning, skilled health worker attendance e.g. midwives, doctors and nurses before, during and after births and effective emergency medical services3. Others have postulated that if there is investment in the health services of a country in general then maternal mortality will follow suit4. Also there needs to be an educational element to the target in the form of advocacy ventures4. These highlight the socio-economic benefits of maternal and newborn health and emphasize maternal mortality as a human rights and equity issue4. One of these measures could be through improved rates of female literacy which empowers women to make informed choices about their reproductive health2. What is the Millennium Development Goal (MDG) for Maternal Health? The UN set up a series of Millennium Development Goals back in 2000 which all world nations agreed upon to eradicate world poverty of which goal 5 is to improve maternal health1. This target can be further subcategorized: reducing maternal mortality by three quarters and increasing universal access to reproductive health4. A wide variety of approaches have been taken and one of the success stories can be found in India. Through a coordinated effort between UNICEF, the Indian government and donors, the Women’s Right for Life and Health project has resulted in a more than 30% increase in the percentage of deliveries assisted by skilled birth attendants in the Rajasthan area5. Members of the community have also put in individual effort as shown by the rise in the number of voluntary blood donations for obstetric emergencies5. The core principles of the programme have even been written into the national health policy reflecting the importance which the government attaches to reducing maternal mortality5. Similar achievements have also been seen in countries such as Nepal, Thailand, Egypt and the Honduras3. Are we on course to improve maternal health? However, this is not a common state of affairs. Increasing evidence suggests that this is the MDG which many countries have made the least progress on. At the global level maternal mortality

decreased by less than 1 per cent between 1990 and 2005 which is significantly less than the 5.5 percent yearly improvement needed to hit the target3. Also there remains a large inequality in maternal mortality between less and more developed countries3; rural and urban areas and those who have been formally educated versus those who have not within countries3. For instance in Niger in Sub-Saharan Africa a woman’s lifetime risk of maternal death is 1 in 7 but in the USA it is 1 in 48003. Women giving birth in urban areas are twice as likely to be assisted by skilled health workers as those giving birth in rural areas3. Addressing the other side of the maternal health issue, the fertility rates in 15-19 year olds remain high in some parts of Sub-Saharan Africa despite the fact that they are falling in other parts of the world reflecting poor access to family planning services. So now we have this knowledge in hand, we should be asking ourselves what can we as students do to improve the situation? If you are itching to help the cause then consider contacting organisations such as UCL Skip which is a part of UCL Medsin. They have in the past organised summer volunteering project in Ghana. This project involved setting up a vocational school for teenage mothers where they were taught skills that would help them to earn a living and providing childcare during their lesson time to make sure there were no barriers to prevent their attendance. Or perhaps you are thinking you need to be more knowledgeable on the subject matter before launching into practical assistance. In this case, I would encourage you to attend the Imperial College Maternal Health Conference on Saturday February 20th which brings together world experts on this field. Alternatively, doing an iBSc in International Health and choosing the module on maternal health will really empower you to have a more detailed discussion and analysis of the issues surrounding this complex topic. This article only touches the surface. So next time you see your mother take time to appreciate her in all her essence. By virtue of being a university student you are an example of what can be achieved when there is excellent maternal health. Iheoma Okpala Fourth Year Medical Student

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Gender Equity What Can We Learn?

n this article I hope to explore some of the ideas in gender equity; in particular, I would like to draw out lessons for countries that may benefit, both in the developing world and in the West. Gender equity has now been identified as a major target for improving the health of populations and I will examine some of the evidence relating to that. This is, of course, a massive field, and a lot of work has been done looking at the sociology of gender in general and its application to health.

This means we can look at the gender ratios of a population to determine if women have an equitable status. If we take the gender ratio to be the number of men divided by the number of women, then the higher this number, the worse off women are (there are not enough women). As Sen points out, in a society with no gender bias, there should be more women than men because women tend to live longer1. Therefore the ‘normal’ value for a gender ratio should be less than one.

The premise of this article is based on the idea that the overall health of a society is better when women have a more equitable status. This is easy to say, but it must be justified. It is important to prove this because it means the implications are that there are good reasons not to diminish the status of women other than moral arguments, that is to say, women at equitable status is not only good for women, but good for everyone.

It is actually very difficult to get this ratio to correlate with health statistics well. Many factors may mask the effect (see table 1). Even taking these into account it is difficult to find a correlation. The reason for this is that as Sen says: ‘many of the discriminations are subtle and covert, and lie within the core of intimate family behaviour. Mortality information can be used to throw light on some of the coarsest aspects of genderrelated inequality.’1

Measuring Gender Equity? We first need to establish a way to measure how equitable the status of women in society is. This is necessary to show that there is an issue in gender equity in many cases and to show the scale of the problem. I will explore two ways in which to do this: gender ratios and female education.

Female Education Female education has been shown in many studies to be linked with positive health outcomes. The level of female

common factor is that these studies find that a more educated female population leads to a better overall health of the population. Kerala, a state in India, is a case in point. Many factors have shown that there is little or no gender bias in the state: as Sen points out in1, adult female literacy was at 86% and was close to total among young adult women at that time1. We can see from the 2006 statistics that Kerala’s GDP per capita was lower than the Indian average giving it very much the income per person of a low income country. However, the infant mortality rate and the life expectancy are good even by Western standards. This is one case where we have shown a relation between gender equity and health. Many other studies and methods have been used to show this as well. Now we can ask why we see this relation. Gender Equity and Health for Developing Countries One of the major reasons thought to contribute to this is that women in almost all societies tend to engage in the work that, if improved, will im-

Gender Ratios Amartya Sen is a renowned academic who won the Nobel prize in economics in 1998 for his work in welfare economics. He looked at measuring gender equity with mortality statistics1. It is clear that if a person has a reduced status in society, then that person is more prone to illness and to worse health outcomes. This is a principle of the biopsychosocial model of health and is shown through many studies on the social determinants of health5. The reasons for this are numerous: for example, such a person will have less access to social support networks that are known to be important in preventing, detecting and treating illness. Such a person would also be more likely exposed to factors that would increase their chances of becoming ill. With gender equity there is an additional factor in some parts of the world where female infanticide is practiced. So, the lower the status of women, the higher their mortality compared to men.

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education of a population has been estimated in many ways – for example some l o o k at the level of female secondary education2 and others look at female literacy3. The

prove the health of the population. This includes many domestic activities that clearly connect with food, lifestyle, hygiene and parenting, to name a few. When this is considered, it is not surprising that gender equity is a very effective exercise in health promotion. For this reason, gender equity should be seen as a public health priority in many develop-

ing countries. This is not just because it is morally justified, but also because it is highly cost effective. There are various reasons for this; a major factor is that this is a strategy for disease prevention. Preventing one person from getting a disease (however you do it) is almost always cheaper than treating that person’s illness. It is also better for that person

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www.uclmedsin.org to never get ill in the first place if we think in human terms. Another factor is that because women are more involved in parenting, their methods are more likely to be passed on to their children. Consequently, if one woman has been better educated it is likely to make a more sustainable difference. However, for this to be a credible way to improve health, it must be possible to create a more equitable society. One might ask how you can change the views of a population if they do not give equitable rights to women. It is possible if you look at how Keralaâ&#x20AC;&#x2122;s state government policy on education achieved this. This is where the governments of developing countries with a commitment to improving health can learn. Gender Equity and Health in Western Countries? We have established that the equity effect on health acts via the mechanism of domestic work done by women (in developing countries). In that case, many of us would like to think that in Western countries, where we are supposed

to have something approximating equal opportunities, that the equity effect on health would not be seen. Ideally men and women would engage equally in domestic work. However, this is proven wrong by studies4 such as4 that have shown that for a married man, the level of education of his wife is more predictive of his chances of death than his own level of education. Therefore, the study shows that even in Western nations, women tend to do more of the healthrelated domestic work. This seems to fly in the face of much of the Western discourse on equal opportunities. This area is a hotbed of dispute in its own right and so I will keep to debates about health. One aspect we might consider is this: we have established that the kind of work done by women is instrumental in determining the health of a population. While the arguments for equal opportunities are completely sound, questions can still be asked. Why has the feminist discourse focussed so much on equal opportunities? Equally, why does a man see it as demeaning to be a stay-at-home parent, allowing his wife to work?

It is as if it is the domestic work that a woman tends to do rather than the woman herself which is not valued. This becomes not a discussion of the status women have in society, but rather a discussion of the status of domestic work in society. No one would deny that in the UK today we have problems with nutrition and lifestyle that manifest as health problems (e.g. smoking and cardiovascular disease). We seem to have problems with parenting that may contribute to issues with social mobility, crime and education. The roots of many of these issues are related to work done in the household and if that work is not seen as important it follows that it will not be done well. This is where Western countries can learn something from global health ideas on gender equity. Rahul Bahl Second Year Medical Student

Table 1: to show how other factors can mask gender equity Country

Gender Ratio

Infant Mortality/ Deaths per 1000 Births

Life Expectancy at birth/years

GDP per capita (inflation and PPP adjusted)/$

Kuwait

1.51

45,950

Ethiopia

0.99

638

Russia

0.86

12,829

UAE

2.11

35,389

Reason for disparity High GDP per capita allows more to be spent on health, Increased gender ratio due to many male migrant workers. Low GDP per capita means less is spent on health. Decreased gender ratio due to high male mortality during war and periods of unrest. Increased gender ratio due to many male migrant workers.

Table 2: to show the effect of gender equity

Country or Region Kerala India China UK

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GDP per capita Life Expectancy at (inflation and ppp birth/years adjusted)/$ 1,924 76 2,297 64 4,536 73 32,308 79

Infant Mortality/ Deaths 15 57 20 5

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Rethinking Mental Illness

hat is the next global health crisis? Which conditions will affect the largest number of people around the world? Some say obesity, others AIDS or malaria. In fact, according to the World Health Organization, more people will soon be affected by depression1 than any other health condition. Yet the social stigma surrounding the problem means that the majority of people are unaware of the number of people affected by mental illnesses: currently, an incredibly high statistic of one in four2 . There are many widespread myths and beliefs concerning mental health: some consider there to be no real cure, while others believe that the patients are to blame for their illnesses. Not only does this mean that people are too afraid or embarrassed to ask for help, but those that do seek assistance and support are marginalised and isolated by society. And despite various measures which are being taken to alleviate the problem, mental illness is a truly serious problem worldwide. Mental health disorders are a universal phenomenon that affects numerous individuals, often, but not always, in tow

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with other illnesses such as cancer and AIDS. Victims are subject to immense suffering: many undergo personality changes and other horrific symptoms. Moreover they are often excluded by the society in which they live, and are left feeling isolated and alone. This is the reason why there is an increased risk of mortality in patients with mental illnesses, for about 877,0003 people commit suicide every year, unable to continue their lives whilst suffering from conditions such as depression, schizophrenia and bipolar disorder. The WHO declared that in 2002, 154 million people around the world suffered from depression, and 25 million from schizophrenia , alarming figures that have only augmented since then: currently, over 450 million individuals worldwide suffer from a mental illness5. Even worse is the fact that the majority of these conditions go untreated. Views from the past Throughout history, mental health disorders have always been feared, and are therefore more neglected than other illnesses where the causes are seemingly

more obvious. Early evidence suggests that any form of depression or anxiety was considered a result of witchcraft, or association with the supernatural. Furthermore, disease in general was seen as a punishment for sins and bad deeds, and so mental illnesses â&#x20AC;&#x201C; or diseases of the mind â&#x20AC;&#x201C; were taken to be the worst form of punishment6. Nevertheless, this view is still shockingly maintained by some members of many different cultures today. Despite the developments in medicine over the past few decades, numerous individuals still associate mental illnesses with institutionalization, mental asylums and electroconvulsive therapy. People with mental illnesses have frequently been associated with violence, aggression and hostile behaviour, often accused of committing criminal acts and involved in dangerous activities. However, what is much less taken into account is the fact that the victims of mental illnesses have more reason to be afraid of violence against them. Indeed, according to World Psychiatry (the official journal of the World Psychiatric Association), approximately twenty

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www.uclmedsin.org www.uclmedsin.org five percent of patients who had been diagnosed with a severe mental illness in the USA had been “victims of at least one violent crime in a year”7. Further evidence has suggested that individuals diagnosed with mental illnesses are as likely to be the victim as the perpetrator of an act of violence. However, the general stigma surrounding mental illnesses globally means that sufferers are universally blamed and further excluded from society.

only a tiny fraction of their national health budgets on mental health. The health services in less economically developed countries are struggling to meet the basic needs of the population, so the increasing prevalence of mental disorders will only exacerbate the situation. Yet the sad truth is that many people refuse to accept the fact that individuals with mental illnesses are equally entitled to good healthcare and treatment, with adequate support and aid.

Solving the problem

Evidence suggests that depression has already become “the biggest health problem”9 in Brazil, where hundreds of people live in appalling conditions in tiny shanty towns. The tense atmosphere between the public and police, together with easy access to illegal drugs means that mental illnesses are extremely prevalent, yet with a poor infrastructure and an underdeveloped health system, help is not readily at hand. International humanitarian aid groups have attempted to tackle the issue head on, but with so many other global health issues existing, assistance is in short supply.

However, the issue of mental illnesses needs to be tackled urgently, since it has been predicted that depression and other such disorders will become one

Mental illnesses are undoubtedly one of the biggest and most difficult problems that the world faces today of the biggest social and financial burdens; hence it is important to address the problems surrounding it. Dr Shekhar Saxena, who works in the Department of Mental Health at the WHO, stated that “in 2030, this will be the single biggest cause for burden out of all health conditions”8. Although many may not agree with his viewpoint, mental illnesses may in fact become more of a problem than is presently feared, owing to the lack of recognition, awareness and knowledge surrounding these conditions. The first Global Mental Health Summit was held last year in Athens, with a view to raise awareness of this aspect of medicine, and to discuss any possible solutions. This is a promising start: acknowledging the immense nature of the issue is the first step in solving the problem. The importance of mental health was highlighted, with a focus on increasing research in the field of neuroscience, in order to develop a better understanding of illnesses affecting the brain and nervous system. Nevertheless, it is the general public that needs to be targeted, since it is the attitudes of the members of today’s society that have to be changed for a real difference to be made in the lives of those affected by mental illnesses today. Global mental health Many people are surprised to discover that mental illnesses are a significant problem in numerous developing countries particularly, countries which spend

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Médecins sans Frontières, one such organization, has recognised the significance of mental health issues, particularly in countries where violence exists continuously, and where war is an ongoing crisis that has become the norm for society. Pictures drawn by children living in Darfur show that they believe that murder and rape are ordinary happenings, and diary entries and accounts given by other children convey the horrors that they have seen. Such children would clearly benefit from some form of mental health treatment, yet sadly little can be done at present. Nevertheless, mental health treatment has encouragingly become part of the aid provided by MSF in these regions, despite the fact that the challenges faced are numerous. Psychiatric treatment and prescription of drugs are both most effective over long periods of time: time which may not be readily available. In more developed countries however, awareness and understanding of mental illnesses has increased, with a considerable proportion of resources being dedication to this aspect of medicine. Various NHS Trusts around the UK, for example, have launched campaigns to increase awareness of the common nature of mental illnesses. A concern surrounding mental illnesses is the overuse of anti-depressant drugs such as Prozac, which are prescribed perhaps all too often by GPs; however, the UK government has recently announced plans to launch a “£170 million pound programme to train psychological therapists… to reduce doctors’ reliance on prescribing anti-depressant medications”10. Nonetheless, the NHS now needs to con-

centrate on spreading resources fairly across the population, for children are becoming increasingly likely to be affected by mental illnesses. Not only is this owing to the high numbers of cases of Attention Deficit Hyperactivity Disorder (ADHD) and autism, but even more so because of the occurrence of disorders related to substance and alcohol abuse. More and more young people are being exposed to drugs such as cannabis and cocaine, which have been shown to amplify the likelihood of mental illnesses horrifically. Looking to the future Mental illnesses are undoubtedly one of the biggest and most difficult problems that the world faces today, yet if treatment and measures are brought into place, hundreds of victims could be living normal lives. By breaking barriers such as a lack of understanding and awareness, and by educating society about the importance of addressing this issue, can we move forward and solve the problem. Mental health disorders are conditions like any other, in that they can be treated, and indeed: “mental illness is nothing to be ashamed of: but stigma and bias shame us all”11. FURTHER READING Go to http://www.msf.org.uk/mental_health.focus to find out more about MSF’s work on mental health treatment Read more about the Global Mental Health Summit here: http://www.globalmentalhealth.org/articles.html Read ‘Going Mad: Understanding Mental Illness’ by Michael Curry and Aine Tubridy Alisha Allana Second Year Medical Student

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After the Tigers

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he island of Sri Lanka located just to the south of India1 is well known as a tropical travel resort. However, the island’s history not been straightforward. The country has endured nearly thirty years of civil war which has left its mark. Since war erupted in 1983 and until its recent termination, according to United Nations estimates, between 80,000 and 100,000 people were killed.2 The fighting forced hundreds of thousands of civilians to flee their homes in conflict areas to live under the most basic of living conditions in hastily built camps. Today, just over eight months since the war ended, nearly 130,000 Internally Displaced Persons (IDPs) remain in these camps; and in the areas of Sri Lanka that were conflict zones, infrastructure is in need of reconstruction – three decades of war have meant that water supplies, schools, hospitals, and community centres must all be rebuilt. The threat of the spread of disease menaces the people still in camps and those repatriated: there is fear that the already inadequate health facilities will be overcome. The war arose from ethnic tensions between the majority Sinhalese and the Tamil minority in the northeast. The Liberation Tigers of Tamil Eelam (LTTE) known as ‘Tamil Tigers’ a rebel group that formed in 1976, pressing for self-

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rule and fighting the government for a separate Tamil state.3 Most of the fighting took place in the north east, which was mainly controlled by the LTTE. However violent confrontations meant that territory often changed hands between the Tamil Tigers and the Sri Lankan military forces. Thousands of civilian lives were lost in the fighting, and also in other parts of Sri Lanka: in the 1990s the LTTE carried out suicide bombings in Colombo, one of Sri Lanka’s largest cities killing hundreds45. In rebel controlled areas, during the war’s worst fighting, remaining civilians’ lives were controlled by complex agreements between the two parties. A control structure was in operation that was ‘A hybrid administrative system that mixed rebel and government civil and political institution [which meant that] while security remained under the control of the insurgents, in health, education and other sectors, the rebels worked alongside government personnel and institutions. But this structure was never capable of providing adequate services to the civilian population on its own.’6 There were several rounds of peace talks which were unsuccessful in reaching an agreement. At the start of the final round of peace talks in 2002, the

LTTE had a territory of 15,000 km2 under their control. In late 2002, a ceasefire and political agreement between the LTTE and the Sri Lankan government was finally reached, through Norwegianmediation.7 On the 26th December 2004, the Indian Ocean tsunami hit Sri Lanka, killing over 30,000 people and displacing more than 700,0008. Two and a half years into the cease-fire, the war-damaged infrastructure, homes, and health facilities in the north east of the island damaged by twenty years of war were progressively being rebuilt. The tsunami was a massive blow to these efforts, as the areas of reconstruction, as well as many buildings that had withstood the war, were destroyed or damaged by this natural disaster. On top of this, the people that were already displaced by the war at the time the tsunami struck were forced to continue living in temporary relief camps9. To deliver aid to the areas behind LTTE lines, the Tsunami Affected Areas Program (TAAP) formed an externally funded system to begin regulation of the reconstruction of the area. It involved existing LTTE aid distribution structures and representatives, and the corresponding government setups as part of a three-way conglomerate with the International Non Governmental Organisations in the area. ‘All sides viewed

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Perspectives

www.uclmedsin.org this as an opportunity to bring the LTTE into the mainstream, and the rebels initially earned plaudits for their effective reconstruction programmes.’10 However, political unrest had not disappeared and there were reports of violations of the 2002 peace agreements by both the government and the LTTE, stalling the peace talks.11 The violence increased progressively between both sides in the years that ensued. Hundreds of people were killed, and the government eventually decided to withdraw from the ceasefire in January 2008 – two weeks later it expired. In January 2009 Sri Lankan troops broke the stalemate and captured the northern town of Kilinochchi, held for ten years by the Tigers as their administrative headquarters. The violence and conflict caused the UN secretary general Ban Khi-Moon to issue a statement on the 11th of May 2009: ‘The Secretary-General is appalled at the killing of hundreds of civilians in Sri Lanka over the weekend. Thousands of Sri Lankans have already died in the past several months due to the conflict, and more still remain in grave danger. The Secretary-General has repeatedly called upon the parties to the conflict to stop using heavy calibre weaponry, including mortars, in the areas with high civilian concentrations. The Secretary-General is deeply concerned by the continued use of heavy weapons in this situation. The reckless disrespect shown by the Liberation Tigers of Tamil Eelam (LTTE) for the safety of civilians has led to thousands of people remaining trapped in the area’.12 The government offensive steadily forced the LTTE to progressively retreat into an area of the north-east, before finally overrunning the last rebel-held position a week after Ban Khi-Moon’s statement in May, when the government declared the Tamil Tigers defeated.13 About 300,000 Tamils fled the war zone into camps during the final offensive against the LTTE, many of whom report having been used as human shields by the rebels. While the state re-established control over the north-east, the needs of the population increased dramatically.14 The Sri Lankan government, led by Rajapaksa, is strict in its allocation of access to INGOs providing aid within the country, and has been especially so since the tsunami. For example, the UN was asked to close down several of its subdivisions towards the end of 2008 in Killinochi ‘forcing foreign staff to leave local colleagues behind as they drove past lines of civilians begging them to stay’15. Demands by local UN staff for greater

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access or increased food supplies are often rejected.16 The large and sudden influx close to 300,000 people from the former conflict zone created significant challenges: the capacity for aid provision by both the government, and the humanitarian aid agencies has been stretched. There were 277,292 IDPs17 in camps, in July 2009. Many have since been repatriated, and now the most recent figure from 6th Dec 2009 is set at 129,196 according to the UN . The government has drawn criticism from the international community for forcefully detaining civilians in the camps. Mr Rajapaksa and the government maintained that this confinement was necessary to allow time for the mines to be cleared from the war zones, for basic facilities to be reconstructed, and also so that a refugee screening process could be implemented for possible LTTE links.19 This process has received criticism from the UN, diplomats and various charities, who have claimed it is not transparent. Mr Rajapaksa pledged to resettle the IDPs by the end of January 2010. In resettlement areas where no central dispensaries exist, there are mobile clinics in place run by the World Health Organisation. This is a temporary set up, aided by the INGOs, in anticipation of the re-establishment of primary structure of health care. WHO doctors are also working the main camp district

hospitals at Killinochchi and Mullaitivu.20 The facilities are incredibly limited, and the conditions are conducive to the spread of disease. The Health Ministry of Sri Lanka has cancelled all foreign tours of ministry officials and government doctors until the 30th of January as a measure of precaution in preparation for a possible epidemic of Dengue Fever. Leptospirosis is endemic in Sri Lanka, and on top of this, H1N1 influenza has been spreading in the country. Dr Pradeep Kariyawasam reported 160 cases from the start of December 2009. “However, some of the cases that were referred to us were suffering from viral flu,” he said.21 This year brings presidential and parliamentary elections, that the government announced would be held early. Sri Lanka continues to face the aftermath of civil war, and natural disaster, and the rebuilding, rehabilitation and restoration are due to carry on in 2010. It remains to be seen whether the government of Sri Lanka will be able to live up to its commitments to re-integrate the Internally Displaced Persons, rebuild communities and re-establish racial harmony. Camille Wratten Second Year Medical Student

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A Hungry World

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en years ago the United Nations outlined the Millennium Development Goals, one of which included reducing the number of hungry people in the world by half by 2015. Now, in 2010, two-thirds of the way to the deadline it looks unlikely that this target will be met. In our world of 6.7 billion people an unbelievable 1.02 billion are still living in hunger. There are several explanations for this failure in famine reduction; population growth, poverty and local climate change. Moreover in the coming years with the chances of more droughts and floods expected in the coming years, this proves to be an additional threat to food security. Almost 1.4 billion people who are earning less than $1.25 per day1 are deemed to be living below the international poverty line and therefore cannot afford to buy the bare minimum to meet their basic food requirements. Global poverty is thought to be the main hurdle that needs to be overcome before world famine can be combated. In famine ravaged countries the lack of food not only affects the individual but has a negative cyclic effect on the countries economy. This is because more of people’s time and energy is spent looking for and obtaining food, this takes from the amount of time they can dedicate to earning an income, thereby feeding the vicious

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circle of low income and unemployment. This has both devastating effects on the individual as well as the economy. The consequences of malnutrition are severe and often fatal. According to the World Health Organisation “poor nutrition and calorie deficiencies cause nearly one in three people to die prematurely or have disabilities”. 178 million children become physically stunted due to lack of vitamins; this dramatically reduces their life expectancy and quality of life. Examples of these conditions are night-blindness due to vitamin A deficiency and kwashiorkor which it manifested as oedema in children with protein deficiency. Additionally infectious diseases cause particular problems as they easily invade vulnerable and undernourished adults and children, this has grave outcomes as these people do not have the immune defences to fight against these otherwise curable diseases. In order to improve this enormous global health issue many different ideas and technologies are being explored. One idea is genetic modification of crops, however this has had mixed opinions from both local governments and aid agencies. GM foods are a way of altering crops so as to increase their content of certain vitamins and minerals to make them more nutritionally valu-

able. They are also a means of ensuring constant food supplies taking into account dramatically varying climates. In theory this type of development seems perfect; however a prominent issue which famine-combating organisations are faced is the realisation that many countries are opposed to this type of farming. Reasons why countries, such as Zambia, have decided not to allow GM crops are that they are not only worried that the introduction of these “foreign” seeds could have detrimental effects on their local crop yields but they also do not want to become even more dependent on aid and large multinational companies for the provision of crops. Similarly a UN investigator, Jean Ziegler stated that “there is plenty of natural, normal, good food in the world to nourish the double of humanity” this view is shared by many humanitarian organisations and for this reason it is believed that GM foods are not the route to solving world famine. Ultimately to achieve this idealistic goal of eradicating world hunger it is important to target the root cause of the problem by improving education, healthcare, hygiene and government policy as well as reducing poverty and ensuring fair trade is taking place. Georgina Gullick Second Year Medical Student

February: Issue 5 B

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No One Gets Cleft Behind

Working with The Northern Cleft Foundation in Nagpur, India

he Northern Cleft Foundation (NCF) is a non-profit humanitarian medical organisation that takes a small team of volunteers to India each year to operate on people with cleft lip and palate deformities free of charge. Interested in global health and the work done by the NCF, I quickly agreed when offered a place on their upcoming trip in January 2010.

The size of the team generally consists of around thirty people, including maxillofacial surgeons specialising in cleft repair, anaesthetists, theatre, recovery and anaesthetic nurses, and the odd medical student. Everyone who comes along is expected to raise money to cover their own travel and accommodation expenses and pay for operations on five children: rental of local hospital space and equipment means that the price of one operation is approximately £100. And so after a few months of vigorous fundraising I found myself eagerly awaiting our departure date.

Flying via Mumbai, we landed at the single-terminal airport of Nagpur city, Maharashtra state, where the 2010 camp would be held. We discussed the plans for the camp over a quick dinner, and put together a rough schedule for the following day. The next morning started with a quick look at the facilities we’d be using – two wards, three operating theatres, and a small four-bed recovery room – and then we began setting up for the day’s operations. After a pre-op assessment of the patients by the surgeons and anaesthetists we were ready to get started. It would take three theatres running simultaneously for nine days to get through all the patients who had turned up for operations.

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Perspectives

Fundamental to the NCF’s work is their tight collaboration with local groups to ensure that when they come to India they are addressing a locally-perceived need, and not just barging in and waving their scalpels around where they’re not wanted. We couldn’t have achieved what we did this year without the cooperation and support of the Rotary Club of Nagpur West (RCNW) who worked hard to locate the patients and bring them to us. The RCNW’s success in this respect was demonstrated by the vast distances patients and their families travelled to reach the camp, some journeying over 250km from the neighbouring state of Madhya Pradesh in order to reach us. Education is also an important aspect of the work done by the NCF, and I accompanied the team’s specialist cleft nurse as she lectured on cleft nutrition to social workers who worked locally in the community. For me this highlighted the fact that the operations we were performing not only affect the children’s lives sociologically – with improved appearance and speech helping them to stay in education – but also affect their general health: by restoring their ability to eat properly the physical fitness of the children will greatly improve, and thus they stand a much better chance of surviving the life-threatening diseases that affect those living in poverty. Working in a hospital in India was an amazing experience. My role on the trip included helping to write up the theatre lists for the subsequent day’s operations, photographing all the patients pre- and post-operatively, conducting an audit of post-operative pain, assisting the surgeons and anaesthetists, making the local staff laugh with my attempts at Hindi, and generally helping out wherever I could. It was useful to come to grips with using basic equipment – ventilating a patient by hand for the duration of their operation – and with how to improvise with what you have in order to get the job done – using wooden spoons as tongue depressors and rolls of tape wrapped in bandage for surgical head supports.

The 2010 camp was the 9th year the NCF has gone out to operate, and was felt by all involved to be a resounding success. Our hard work even caught the attention of the press, and we were featured in an article in The Times of India (Friday, January 22nd 2010, pg 5). Veteran members of the team who had attended the previous camps agreed that this year we’d worked harder than ever before, performing 103 operations in 9 days (and 1 latecomer on the 10th day!) and bringing the running total of free operations performed by the NCF since its inception to over 500. It was with a feeling of exhaustion coupled with elation at what we had achieved that we boarded our flights back home to the UK. Every year the NCF takes along a handful of medical students and junior doctors who are interested in getting experience. I would particularly recommend the camp for those with an interest in anaesthetics and maxillofacial surgery. For more information see the NCF website: www.northerncleftfoundation.co.uk Andrew Lewis Fourth Year Medical Student

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Save the Humans “The impact on human health is the most significant measure of the harm done by climate change.” (Dr. Mar-

garet Chan, WHO DirectorGeneral)

ecember’s UN Climate Change Conference presented our world’s leaders with the chance to advocate a purposeful political deal that would establish coherent targets and an explicit timeline for their rendering into law. In reality, the meeting in Copenhagen was a letdown. We did not secure any targets for reducing global greenhouse gas emissions by 2050 or any commitments to a legally binding treaty. The relationship between climate change and health is obvious, and the health problems it exacerbates are mostly faced by the developing world. In failing to set a deal to save our planet’s health, the health of our planet’s people is now in even greater peril. Climate change yields death and disease from water shortages, food scarcity, flooding, drought, air pollution, and much worse. On top of this, many diseases, including common vector-borne disease such as malaria and dengue fever as well as extreme killers such as malnutrition and diarrhoea, are highly sensitive to temperature and precipitation fluctuations. The Protecting Health from Climate Change Report predicts that the African population at risk from malaria will rise by 170 million by 2030,

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and the global population at risk of dengue fever by 2 billion by the 2080s. As the malaria-carrying mosquitoes migrate, the disease has already begun to be reported in areas that have never reported cases before. Even today millions are dying from climate-sensitive diseases; 3.5 million from malnutrition-related causes, 2 million from diarrhoea-related diseases (almost all children) and 1 million from malaria. The progress we have slowly been making towards eliminating these diseases will be eradicated by the impact of climate change. Although climate change is undoubtedly a global predicament, it is the developing nations which bear the greatest burden of the consequences. Those particularly vulnerable will be the develop-

ing country populations in Small Island States, arid and high mountain zones, and densely populated coastal areas. The fragile healthcare systems of the developing world will endure even more strain as they attempt to cope with increases in existing diseases as well as a rise in new climate change-related health issues. With the world home to one billion people already living on the brink of survival, this will be the final push. Accompanying this dilemma is the fact that the majority in the developing world rely upon agriculture for their livelihoods and existence. How and what crops are grown will be massively affected by prolonged water scarcity or too much water. The productivity of the agricultural sector and subsistence farming in Africa is predicted to fall by as great as 50% in the coming 20 to 30 years. “Can you imagine the impact on hunger, on acute and chronic malnutrition?” (Dr. Chan). Dr Diarmid Campbell-Lendrum, the lead author of the Protecting Health from Climate Change report, professes that “climate change threatens the very fabric of global health”. “We have a choice between a world that is more dangerous, worse for health and more degraded and unfair, and one that is more sustainable, equitable and beneficial for health”. Health has for far too long been sidelined by the policy makers for climate change, it must now come to the centre of debate. Nidhita Singh International Health IBSc

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The Art of Campaigning Vishaal Virani provides an insight into the influential world of campaigning, and discovers it’s not just for those hardcore tree-hugging, anarchist types

et’s start by stating the obvious; you are probably reading this magazine, and this article for that matter, because you are interested in addressing global health injustices. No doubt many of you have contributed to successful fundraising events such as marathons, swimathons and even allyou-can-eatathons. The question is how many of you actually feel like you are making a difference? This is a fundamental issue that should be considered by any conscientious fundraiser. Even supersize donors such as Bill and Melinda Gates cannot accurately determine the net benefit accrued from their contribution. My intention is not to undermine the value of financial generosity, but instead to extol the virtues of an alternative form of aid; campaigning for change. When one mentions campaigning, the stereotypical visualisation is of anarchic activists and hippies chaining themselves to Mr. Brown’s humble abode, or even the nearest tree. However, the reality is that campaigning is an imminently accessible and effective means of making a difference. The obvious benefit for students is that it is costeffective (often free). In addition it is also time-effective, as campaigning often simply involves a click of the mouse. The Influence of the Electorate So what exactly is campaigning? Well the dictionary definition goes like this “an operation or series of operations energetically pursued to accomplish a purpose”. Let me use a political context, a sphere in which campaigning is particularly influential, to flesh out the dictionary definition. During the Medsin National Conference last year I wrote a letter to my local MP demanding that the UK government abide by their pledge to give 0.7% of GDP to developing countries by 2013 (our government currently gives about 0.3%). Several other delegates also performed the operation of sending a letter to their local MP, as a means of achieving the same purpose. If a significant proportion of the electorate also write a similar letter, then the pressure this exerts on the government would force it to at least raise the issue

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in parliament, and subsequently address it. Although the process is slow, and politics a very bureaucratic field, this form of political campaigning is highly effective. The crux of the matter is that your local MP and the national government must please their electorate; therefore if you, along with others, raise an issue then politicians must address it or risk losing your support at the next election. Let me give you an example of a successful political campaign in California, USA. Appalled by the conflict in Darfur, a Californian non-governmental organisation called Sudan Divestment Task Force (SDTF) was created. The SDTF recognised that foreign investment in Sudan was indirectly bankrolling the conflict. Therefore the SDTF set-up a campaign to encourage American individuals, organisations and companies to divest from those companies which were investing in Sudan. Following extensive campaigning amongst the general public and local politicians the SDTF succeeded in presenting the issue to Arnold Schwarzenegger, the Governor of California. Schwarzenegger approved the proposal, and therefore in California it is now prohibited to invest in any company that has direct investments in Sudan. 5 Simple Steps Hopefully you can now understand the significant benefits of campaigning, and are wondering how to go about mobilising a campaign. The five key components of a successful campaign are the following: 1. Clearly state the purpose of your campaign from the start, and ensure everyone involved with the campaign agrees on this purpose 2. Strength in numbers – isolated individual actions will not bring about change 3. Ensure that those coordinating the campaign are well informed on the all aspects of the issue, and feel strongly about the issue 4. Approach key individuals and organisations, such as your local MP and the media, to ensure they are made aware of your campaign 5. Budget your campaign carefully – you will need funds for flyers and hosting events; campaigning electronically can help reduce your costs There are many ways for you to get involved with campaigning right away. Firstly, I hope that having read this magazine and attended the first few Medsin meetings of the term some issues have been raised that you feel strongly about

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and wish to address. Channel this passion into a positive campaign using the guidelines summarised in the previous section; tell a friend or three about your campaign and tell them to pester someone else. In this way your campaign will soon evolve into a politicians worst nightmare. If this article does inspire you to initiate a campaign then please do let the lovely people at Medsin UCL know (medsin.ucl@gmail.com). Alternatively you can contribute to an existing campaign, because after all without supporters even the best-planned campaign will not succeed. Medsin UCL are running several successful campaigns this academic year. To find out more please www.uclmedsin.org. Finally, an essential campaigning website to visit is www. avaaz.org. Avaaz is a global campaigning organisation with over 3.5 million members. It runs regular campaigns on important global issues such as Climate Change, Torture in Guantanamo, and the Global Food Crisis. It has already run 13m campaigns since 2007 and it is well worth signing up to their mailing list. So I hope this article has introduced you to the wonderful world of campaigning, and inspired to start making a difference. In the famous words of Banksy “keep your coins, I want change”.

Vishaal Virani Fourth Year Medical Student

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Perspectives

Event Reviews West African Country Evening

Economics theory suggest that the wealth of a nation is determined by its amount of capital and labour force. Healthcare issue has, hence, to be addressed in a way that considers people as indispensable asset to achieve development. Dr Ayodele Kazeem research fellow at the Imperial College emphasizes the special cultural aspect of the healthcare issue in Africa. He recounted his experiences in Nigeria, where curing is often thought to be achievable through ritual practices rather than by conventional medical treatments and consequently, the limited persuasion of prevention campaign such as for AIDS. During this evening, Dr Chikwe Ihekweazu, former consultant at the WHO and currently a Consultant Medical Epidemiologist, stressed the urgent need for modern infrastructure, to address both the pressing demand for cares and also tackle the medical personnel exodus. Dr Chikwe Ihekweazu’s views can be followed on his blog :http://www.nigeriahealthwatch.com. The west African country evening also featured an excellent selection of West African food and fashion shows presenting African-inspired student’s creation. It was both an informative and enjoyable evening and look forward to more events organised by UCL Medsin. Jonathon Yao-Bama Postgraduate student at SOAS

Public Lecture: Why Aid is Not Working and How There Is Another Way for Africa Speaking at the London School of Economics as part of her book tour, respected Zambian economist Dr Dambisa Moyo presented a convincing argument for an end to intergovernmental aid to African states. Despite the provocative title, she was keen to clarify that her case referred specifically to intergovernmental aid, rather than emergency or charity aid. In her book, ‘Dead Aid: Why Aid is Not Working and How There is Another Way for Africa’, Moyo outlines 10 reasons why aid is detrimental to African economies, and she shared several of these with us during the evening. She started by bringing our attention to the unhealthy disparity between the level of income African governments receive from external support, and the income they glean from taxation. Accordingly, it is in governments’ interest to focus their energies on their sponsors, creating a political dynamic that severs the relationship between a government and its people. This pernicious relationship permits the abdication of responsibility, rather than demanding accountability, creating dysfunctional government. She cited the occurrence of well-recognised economic consequences of foreign aid, namely ‘Dutch Disease’- a scenario created when external investment results in the abundance of a country’s currency, reducing the competitiveness of its manufactured exports- as evidence of the negative impact that aid is having, in its current form. Next, Moyo argued that the aid relationship demands a desperate depiction of Africa that must be propagated by the continent if it wishes to continue to receive financial support. Such negative portrayals corrupt public morale, undermining the

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development of pride in one’s own nation. She highlighted her point by contrasting the global perception of Africa with that of China and India, attributing much of the difference not to the numbers living in poverty, but to the actions taken by the respective governments’ in public relations. Dr Moyo went on to talk about debt burdens, inflation, and the importance of job creation, but refused to divulge the full contents of her book, leaving the remainder of her ’10 reasons’ as an incentive to purchase a hard copy of her argument. Following her talk, the floor was bursting with questions, some loaded with praise and others edged with criticism. While she fielded the challenges to her argument with confidence, she was keen to emphasise that her expertise lay in the field of economics and not political science. Not an economist myself, and a complete novice in the field of development, I found Dr Moyo’s talk wholly accessible and clear. She is a fresh, candid and challenging voice in this controversial debate. Dead Aid : Why Aid is Not Working and How There is Another Way for Africa by Dambisa Moyo Robin Baddeley IBSc Student in Clinical Sciences Sheffield University

February: Issue 5 B

Perspectives

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Reviews The Age of Stupid If you have managed to avoid the unrelenting bombardment of activist documentary style films of recent years, you would have to be one of exceptionally few. Director Franny Armstrong, who is well known for her previous protest against fast-food giants in the form of film-documentary ‘McLibel’ (2005), successfully combines a futuristic, rather frightening, documentary theme film focusing on the subject of climate change in her latest film ‘The Age of Stupid’.

Al Gore-fronted An Inconvenient Truth (2006), but this does not distract from the take home message of absolute need for necessary change to take place. Through its pace and urgency, and the smooth integration of hard facts, this film really hits home and truly deserves to be seen. Lucy Reeve Third Year Medical Student

Set in 2055, when London is underwater, Sydney on fire and the Taj Mahal in ruins, the film focuses on the last man alive, Pete Postlethwaite who resides in a tower just off Norway. Using his super sci-fi touch screen technology, he chooses to look back to 2009 and beyond in order to uncover how exactly man kind was able to just sit back and watch the world destroy itself like that. Watching actual footage from the 1970’s, he muses sorrowfully on how humankind could have been so stupid, ignoring the environmental warning signs. Six main stories are followed, each one successfully bringing home Armstrong’s message; that change must come from people as much as from governments. From Melting glaciers to hurricane Katrina, each story examines the unique, unpredictable consequences of not taking action while we have the chance. Armstrong is an astute journalist, travelling the world to track down both people and communities that can illuminate her central question: how can consumerism and all the social and psychological destabilisation that it produces be controlled? As in her other films, Armstrong uses ‘The Age of Stupid’ to cleverly investigate this question and raise similar thoughts in the viewers, gently extracting our heads out of the sand. ‘The Age of Stupid’ is far more emotionally charged than the

Cry Freedom “CRY FREEDOM” is a 1987 British feature film directed by Richard Attenborough who also directed the academy award winning film “GHANDI”. Donald Woods (Kevin Kline) is chief editor at the liberal newspaper Daily Dispatch in South Africa. He has written several editorials critical of the views of Steve Biko (Denzel Washington). However after meeting him for the first time, he changes his views. They meet several times, and this means that Woods and his family get attention from the security police. When Steve Biko dies in police custody, he writes a book about Biko. The only way to get it published is for Woods himself to illegally escape the country. Cry freedom powerfully and informatively illustrates the effect of apartheid on the black people of South Africa in the 1970s. It shows the inhumane environments and difficult circumstances that black South Africans of every age, young and old had to live with for years. For instance Biko tells Woods in the film, no matter how smart you were as a child, as long as you were born black, you would remained constrained in that environment with no opportunity to learn or grow. The world would never benefit from your potential and I certainly believe that anyone who sees this film will empathise with Biko’s pain; that his people have a heritage and a land that is theirs to enjoy to the fullest but cannot, in fact, dare not, as an individual will never develop your talents. (Paraphrasing) What can we, as students learn from this film? That it was not all gloom and doom; we learn throughout the film that because one man, Woods took bothered to understand, he was transformed. One meeting led to a journey of determination and

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hardwork to fight apartheid in South Africa. The movie also highlights the strength and the sense of community between the black South Africans then; setting up schools to train people and small clinics to ensure that people could get adequate treatment. Finally, that you can actually make a difference, you can stand up for what is right. Woods and Biko’s journey involved a partnership; Biko didnt label Woods as a typical and regular White South African and Woods was ready to learn as well as sacrifice for the greater good. This film gives a stirring account of two men’s heroic efforts to let the wolrd know about apartheid in South Africa and hopefully make a change. If you have not seen it, it’s a fantastic film to watch; its stomach churning, powerful, thought provoking and challenging and will undoubtedly leave you a changed person. “The most potent weapon in the hands of the oppressor is the mind of the oppressed.” Steve Biko- Speech in Cape Town, 1971 Efun Akerele Co-president of Medsin UCL

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“The fact that so many people are poor and live in an unequal world creates a crisis that affects us all. Poverty not only gives rise to diseases that can spread around the globe, it also jeopardizes national economies and endangers social and political security. As humans, we are bound together and ultimately we will sink or swim together.” – Archbishop Desmond Tutu, Nobel Peace Prize Laureate

55: the average life expectancy at birth

for babies born in 2007 in the world’s least developed nations, compared to 79 in the world’s most developed nations.

87% of the world’s population use improved drinking-water sources (2006)

10 facts &figures 33% of people in the

world’s least developed countries use improved sanitation facilities (2006)

38% of under-fives

worldwide have diarrhoea and receive oral hydration and continued feeding (2003-2007)

15,000,000 children orphaned by HIV/

AIDS worldwide

The right to health is “an inclusive right extending not only to timely and appropriate healthcare but also to the underlying determinants of health...” - UN International Covenant on Economic, Social and Cultural Rights

130: the under-five mortality

rate (per 1000) in the world’s least developed countries, compared to 68 for the world’s most developed nations. (2007)

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The WHO “estimates that better use of existing preventative measures could reduce the global burden of disease by as much as 70%”

33,000,000 people living with HIV/AIDS worldwide in 2007

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Calendar 16th February:

21st Century Challenges: how global crises provide the opportunity to transform the world Time: 6.30pm Location: LSE, Old Theatre, Old Building Speaker: Professor Professor Lord Anthony Giddens, Professor David Held, Professor Mary Kaldor, Professor Danny Quah

20th February:

Woman’s and Maternal Health Conference 2010 Time: 09:15-17:00 Location: Imperial College London Contact bhavna.oza@imperial.ac.uk or lara.payne08@imperial.ac.uk with queries.

22nd February:

Tuberculosis Time: 5:15 pm 6:15 pm Venue: John Snow Lecture Theatre, LSHTM, Keppel Street, London WC1E 7HT Speaker(s): Ruth McNerney

25th February:

Turning the world upside down - the search for global health in the 21st century Time: 12:45 pm - 1:45 pm Venue: John Snow Lecture Theatre B, Keppel Street, LSHTM, London WC1E 7HT Speaker(s): Lord Crisp, Honorary Professor, Independent Crossbench Member, House of Lords and Chairman, Sightsavers International

26th February:

The influence of distance on health facility delivery in rural Zambia Time: 12:45 pm - 1:45 pm Venue: Curtis Room, LG9, South Courtyard Building, LSHTM, Keppel Street London WC1E 7HT Speaker(s): Sabine Gabrysch, IDEU & University of Heidelberg

2nd March:

LUNCH HOUR LECTURE: Energy and climate change; clearing the fog Time: 13:15 - 13:55 Venue: Darwin Lecture Theatre - accessed via Malet Place, Darwin Building, UCL, Gower St, London, WC1E 6BT

3rd March:

Medsin UCL presents: South Asian Country Evening Time: 7pm - 9:30pm Venue TBC Editor’s Choice

8th March:

The preventability of cancer Time: 5:15 pm - 6:15 pm Venue: John Snow Lecture Theatre, LSHTM, Keppel Street, London WC1E 7HT Speaker(s): Prfoessor Isabel dos Santos Silva

14th March:

MSF Fun Run Venue: Regent’s Park Contact fomsfrun@googlemail.com

15th March:

Global mental health: the call to action Time: 5:15 pm 6:15 pm Venue: John Snow Lecture Theatre, LSHTM, Keppel Street, London WC1E 7HT Speaker(s): Professor Vikram Patel

16th March:

Beyond Copenhagen Time: 12.30-14:00 Location: LSE, Old Theatre, Old Building Speaker: Professor Lord Stern

18th March:

Disability and Poverty - A Perspective from the World Bank Time: 5pm – 7pm followed by drinks until 8pm Location: Wilkins Old Refectory, University College London, Gower Street, WC1E 6BT Speaker(s): Daniel Mont (World Bank)

February Issue 5

Page 27B

Medsin UCL presents...

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

We are currently recruiting: Editors Proofreaders Designers Writers Photographers No previous experience is required; all that we ask is that you have a passion for global health. All students are welcome! To get involved or for more information please contact: medsinmagazine@gmail.com

To view/download the magazine please visit www.uclmedsin.org or email medsinmagazine@gmail.com for a printed copy

UCLU MEDSIN RUMS SOCIETY Published on behalf of UCLU Medsin RUMS by Zaneta Forson & Efuntunde Akerele