Issue 6 - UCL Medsin Perspectives Magazine by Medsin UCL

Perspectives Global Health Magazine UCLU Medsin Society Stop AIDS Issue

Perspectives

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Letter from the Editor

elcome to the first issue of Perspectives for this academic year. This summer was filled with major developments in global health, and as a result the editorial team has had an exciting, yet difficult time selecting what to pack into this issue. Only shortly after the devastating natural disaster in Haiti, the world’s media was dominated by images of the devastating floods in Pakistan. Many people were appalled and even high-profile celebrities, such as the dragon’s den James Caan, travelled there to give assistance. The blog ‘Welcome to Jamshoro’ documents one dynamic student’s experience of volunteering in such high pressured circumstances. However, the voluntary assistance and the work of NGOs is just one part of resolving the issues surrounding natural disasters. ‘A Problem is Not a Problem When No One’s Watching’ addresses the increasing role the media plays in forming public opinion towards health policy and aids distribution. In a world where globalization is a key focus, who decides what constitutes a global health issue? There is no doubt that HIV/AIDs is finally gaining recognition as a global health concern and in support of the Medsin ‘Stop Aids’ week running from the 29th November – 3rd December, this issue has a variety of articles addressing the multi-faceted subject that is the HIV/AIDS epidemic. For those of you that are not so familiar on the complexities of the disease, ‘Setting the Record Straight’ provides a wonderful introduction and ‘Beyond Behaviour’ questions the future of HIV policy. In her interview Heidi Larson manages to pinpoint why this Perspectives issue proves so important and engaging: ‘AIDS touches nerves in politics, ethics, human rights, society as a whole, media, everywhere’. UCLU Medsin got off to a great start this term, engaging students across all disciplines at the conference on ‘What can students do for global health?’ For those of you that missed it, well shame on you but fortunately Perspectives was there and the review ‘Turning Passion into Action’ proves both insightful and enlightening. (But check the calendar at the back to ensure you, won’t miss anymore important events!) I know this Perspectives issue will inspire a great deal of people into taking up a cause, or spur debate around an article. So please do let us know your thoughts by e-mailing medsinmagazine@gmail.com and we shall be launching our blog spot at www.uclmedsin.org very soon. Get ready to be inspired. Annabel Sowemimo Perspectives Editor

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Perspectives

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Contents

Current Affairs

Is AIDS still important?

Where are the drugs?

Setting the Record Straight

Interview with Heidi Larson

Beyond Behaviour

Rationality, Medicine and ADHD

The Mediaâ&#x20AC;&#x2122;s Influence on Global Health

First In, Last Out

The Medicalisation of Childbirth

Interview with Bryan Pearson

Pakistan Floods

Pakistan Flood blog- Welcome to Jamsboro

News in Numbers

Event Review: Turning Passion into Action

Reviews

Calendar

The Team Chief Editor Core Editors Head Designer Proof Reader Webmaster

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Annabel Sowemimo Katherine Law Alisha Allana Adaugo Amajuoyi Chibuzo Mowete Camille Wratten Anna Schultze Joel Cunningham

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Perspectives

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Current Affairs Three decades since his pioneering work on in-vitro fertilisation (IVF), the American physiologist Robert Edwards has been awarded the Nobel prize for medicine. Edwards was a leading figure in reproductive science for the second half of the twentieth century, with the culmination of nearly thirty years work resulting in the 1978 birth of Louise Brown here in the UK. Infertility, defined as an inability for a couple to conceive within two years, is estimated to affect more than 10% of the global population. For infertile couples deprived of the chance to start a family, the trauma and strain can be huge. The work of Professor Edwards, has provided these couples with a means to creating a family – since its first successful use in 1978 more than four million children have been born using IVF. The process used for IVF is a delicate one, requiring expensive equipment, laboratories and highly trained staff. Put simply, eggs from the ovaries of the mother are retrieved and are either mixed or injected with sperm from the father or a donor. The fertilised egg is then replaced into the mother’s womb and the child should hopefully be carried to term as usual. The success rate for IVF, while improving, does still remain low with couples often having to pay for successive cycles before conceiving. The costs associated with IVF leave it a technique not available to all in developed countries, let alone in underdeveloped countries. The science of reproduction is still poorly understood and remains in its infancy. As we have seen with other expensive developments in treatment originating from the western world, they take a long while to be translated to a cheaper option freely available to those in low income countries. While IVF is not necessarily a life saving treatment, it does alleviate the pain infertility brings to couples and sadly its availability does remain skewed towards wealthy couples in the developed world.

www.bbc.co.uk/radio4/womanshour/01/2009_37_fri. shtml

Nobel Medicine Prize awarded to British IVF pioneer

IVF has not gone without its fair share of controversy. Influential members of the Roman Catholic church, with a global membership of over 1.1 billion people, were vociferous in their condemnation of the process. Concerns over its safety have also arisen within the scientific community, although most follow up studies of children conceived by IVF have proven no foundation for these claims. Despite this resistance IVF appears to be a success story, with a promising future ahead and the elimination of infertility as a problem for many couples worldwide. Arguments for or against IVF should not detract from the individual achievement of Professor Edwards in bringing his 1950’s concept of the process to fruition in 1978 after thirty years of dedicated work. The research he has done has allowed millions of people to become parents who otherwise would not have had the chance, a feat now rewarded with one of the most prestigious awards in science – the Nobel Prize. Martin Everson Medsin Co-President

Health officials have declared that the number of people infected with cholera in Haiti is just over 4000. With the total death toll nearing 300, and authorities stating that the epidemic has not yet reached its peak, the country is preparing for the worst. Cholera is an intestinal infection that thrives in conditions of poor hygiene and sanitation. Whilst such conditions are rife across the country, sanitation was poor even before the earthquake hit. Furthermore, the region most affected with the disease is central Haiti, which was not the area most affected by the earthquake. Officials are working hard to determine the cause of the outbreak in order to limit further spread. The cholera epidemic is yet another setback to the country and the imminent arrival of Hurricane Tomas may worsen the situation. The infection causes vomiting and diarrhoea leading to dehydration which could be fatal in a matter of days. Authorities have been urging people to boil food and water and avoid raw vegetables to decrease the likelihood of transmission. Fears are rising that the outbreak may spread to neighbouring Dominican Republic, and the government is already taking precautionary measures. Ngozi Mowete Fourth Year Medical Student

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http://www.topnews.in/health/regions/switzerland

Cholera Hits Haiti

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Stop AIDS campaign message: Is AIDS still important?

Perspectives

Why students should care and what we can do?

ince the first cases of AIDS were reported in 1981 (then known as GRIDS, Gay Related Immuno-Deficiency Syndrome) some 60 million people have become infected with HIV, and 25 million of those have subsequently died from it. As a cause of death HIV accounts for just 3.5% of global mortality, though this rises to 5.7% in low income countries. So are we “all tested by this crisis”? This implies that we not only all care about the issue, but that we all have the capacity to change it to some extent and the “test” is in our willingness and aptitude to effect that change. But is this true? After all, the UK is not a low income country, no matter how hard up you feel when your loan has not come through, and in 2008, just 525 people in the UK died of HIV related complications (less than 1% of HIV positive people, themselves just 0.13% of the UK population). So why should we be worried about it?

If we recognise health as a goal in itself, we should be concerned about the impact of HIV. If we are driven by a desire to further international development (whether to improve national security, foster trade or even through altruism), we should be interested in AIDS. It is true that in the nearly three decades since AIDS first emerged, the public have learnt a lot about HIV – the virus that causes AIDS, how to prevent transmission of HIV, how to treat it and how to control an AIDS epidemic - but

Another application for our knowledge is in the field of HIV medication. In 1996, the first antiretroviral therapy (ART) hit the market to treat HIV. However, their expense (around $15 000 per patient per year) prevented their widespread use across the resource poor settings where treatment was most needed; five years after the introduction of ART, less than 8 000 people in Sub-Saharan Africa were on treatment. Almost a decade of campaigning and advances in drug design have seen the cost of ART fall to just $88 per person per year, and by the end of 2008 more than 4 million people worldwide were receiving treatment. According to UNAIDS, this still represents just half of those people who need treatment, and there is much we can do to improve this. UNITAID has recently created a “patent pool” for HIV medication, inviting drug companies to produce “generic” drugs at a fraction of the cost. The challenge now is to lobby pharmaceutical companies to agree to put their drugs in the pool to further decrease the cost of HIV treatment.

“We are all sick because of AIDS — and we are all tested by this crisis.”Barack Obama, World AIDS Day 2006.

The “low” HIV death rate (5.7% still makes it the fourth leading cause of death in low income countries, and the most deadly infectious disease) masks huge variation; AIDS is not a universal ‘African’ problem. Whilst in Swaziland a quarter of the adult population has HIV, less than one percent of Senegalese adults are infected. The impact on health services in much of Southern Africa, where HIV prevalence is the highest, has been profound. Swamped by the sheer volume of people with HIV and their related opportunistic infections (HIV weakens the immune system making people more susceptible to other diseases), the health service cannot even begin to tackle other health problems. AIDS also disproportionately affects the sexually active population, which closely correlates with the working population. Countries that lose up to a third of their workforce (with an increasing the strain on the health system) can expect to have their economic development severely damaged. The World Health Organisation (with UNAIDS) approximated an HIV prevalence of 10% is enough to impact upon a nation’s economic growth.

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the Leading experts are continually publishing new research and reporting new findings. The learning curve continues, and the first thing we can do is drag ourselves up that curve. Then we can start implementing our new knowledge and using it to influence decision makers. This may sounds farfetched, but we all know that HIV causes AIDS and it is passed on (amongst other things) through sexual contact. Until 2008, though, the South African government were heavily criticised for their slow response to the HIV/AIDS epidemic, due largely to a health minister who promoted eating garlic to stave off infection rather than safer sex, and refused to recognise HIV as the causative agent of AIDS. Research has suggested this sluggish, misguided response caused up to 330 000 AIDS related deaths between 2000 and 2005 in what has been referred to as “genocide by sloth”, eventually brought to an end by domestic and international pressure.

Those are just two examples of how simple knowledge can translate into campaigns which change policy and transform epidemics. Towards the end of this term, UCL is hosting a week of events around World AIDS Day (December 1st) which will educate us all about how we can make a tangible difference. We will set to dispel some common myths about HIV/AIDS - ‘Setting the Record Straight –The top ten myths about HIV/AIDS’ and to investigate the complexity of the AIDS problem - ‘Beyond Behaviour - seeing the bigger picture in HIV policy’. The week presents an ideal opportunity to learn from world leaders in HIV, and a real chance to shift that new knowledge into well thought out campaigning and advocacy. Join us for panel discussions, policy workshops, film screenings and the odd party to see how you respond to the test of the AIDS crisis. Isaac Ghinai Medsin Co-President and leader of Medsin’s ‘STOP AIDS’ campaign

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Perspectives

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Where are the drugs?

Access to HIV Treatment in Developing Countries

he HIV/AIDS epidemic is one of the most serious challenges facing our generation today. The World Health Organisation reports that in 2008 worldwide there were 33.4 million people living with HIV, 2.7 million people newly infected with HIV, and 2 million people that died as a result of the infection (280 000 of whom were children) . In 2009 the antiretroviral (ARV – the recommended treatment for HIV) coverage was 36% worldwide and 11% in North Africa and the Middle East . This is an improvement on past levels of coverage but conversely the unmet need for ARVs in North Africa and the Middle East is still 89%. The number of people not receiving treatment in this area is shockingly high, especially when compared to the much higher levels of coverage of ARVs in the west. If access to essential medicines is a basic human right why does this global inequality of access to treatment exist and what can we do about it?

“the unmet need for ARVs in this area is still 89%.” “10 million people in the world lack access to existing essential medicines” The problem of access to medicines is complex and multi-faceted. 10 million people in the world lack access to existing essential medicines due to barriers including cultural and social factors, geography, conflicts, health systems, drug availability, and financial obstacles, to name just a few. One of the major barriers facing people in developing countries is that they often have to pay for medicines out of their own pocket, and for many the price is just too high. In Senegal, treatment for a disease course is unaffordable for 40-70% of the population once it is over just $1 a day . Intellectual property regulation is an important factor in the development of these prices that are so far out of reach for the poorest in society. Currently when a researcher, say at a large UK university such as UCL, makes a new discovery they patent it. This means that they protect it as their intellectual property so no-one else can use it without their permission. It is often transferred to a company to be developed and produced. The company then has a monopoly on that product, whether it is a new drug or a new technology, for 20 years. As the only producer in the

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market they can charge as high a price as they like, which is often in excess of what is needed to recoup the cost of developing the drug and also often far more than people in developing countries can afford . The laws that govern this process are set out by the World Trade Organisation (WTO) in the TradeRelated Aspects of Intellectual Property Rights Agreement (TRIPS) . TRIPS may enshrine a 20 year monopoly on intellectual property, but it isn’t all bad news. In 2001 the WTO released the Doha declaration which clarified some provisions of the original TRIPS agreement for ensuring access to medicines in developing nations. According to article 31 of the TRIPS agreement, if a country claims a national or public-health emergency then they can make cheap generic copies of a drug which is still covered by the 20-year patent protection. Or, if that country doesn’t have the facilities to manufacture the drug themselves, then another country can make it for them and then they can import it. Generic production means that many producers can make the same drug. This introduces competition between the producers and drives down the price of medicines . But producing affordable drugs in developing nations isn’t easy, and the provisions of the TRIPS agreement have almost never been used. The country that is generally thought to have had the most success is India.

“ India is often described as ‘the pharmacy of the developing world’ but this important source of HIV treatment for developing countries is under-threat” In 2008 the Indian generic pharmaceutical industry produced 87% of the purchase volumes of ARVs for developing countries, 91% of the paediatric volumes and has allowed 4 million people to start HIV treatment in the five years since 2003. . India is often described as ‘the pharmacy of the developing world’ but this important source of HIV treatment for developing countries is under-threat from the current Free Trade Agreement negotiations between the European Union and India. There are concerns that the European Union could pursue measures that would extend the length of time patents are protected for, that would require lengthy and expensive clinical trials before generics could be produced and allow generics to be confiscated while in transit to developing

countries. This issue should concern us as citizens of the European Union, but are there are also matters that affect us as citizens of our respective universities? University students have been shown to have a considerable role to play in global access to medicines. In 2001, Yale University realised that an antiretroviral drug (stavudine) discovered at their university was being produced by the pharmaceutical company Bristol-Myers Squibb but priced so high that it did not reach HIV sufferers in South Africa. They launched a successful campaign with Médecins Sans Frontières and managed to get the drug produced generically in South-Africa which resulted in a 30-fold reduction in price and the rapid expansion of HIV-treatment programmes . The student movement that started at Yale has since grown into an international not-for-profit organisation called Universities Allied for Essential Medicines (UAEM). UAEM now has over 90 branches in 14 countries in the global north and south (including UCL, where I am a member). The ideas that developed at Yale in 2001 have since solidified into a unified set of aims . Firstly, that there should be access to medicines and medical technologies developed at universities in low and middle-income countries through provisions for generic production in these countries. This would involve a small change to universities’ intellectual property transfer agreements but would mean that the price of medicines in developing countries could be dramatically reduced. Secondly, that there should be more research and development into neglected diseases, for example, chagas disease. Chagas affects 10 million people who live almost exclusively in Central and South America . It is a parasitic disease caused by the protozoan Trypanosoma Cruzi and can cause life-threatening heart and digestive disease. The current treatments are anti-parasitics such as benznidazole and nifurtimox but these do not provide an effective cure. This condition, and many like it, affect mainly the world’s rural poor and as such do not constitute an attractive market for pharmaceutical companies. Much more needs to be done to develop innovative solutions for the current lack of research into neglected diseases. The final aim of UAEM is that the fruits of university research should be valued on the positive global impact they have rather than the financial gain. Together these interventions would have a significant positive impact on the worldwide inequality of access to medi-

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Perspectives

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A university researcher makes a new discovery (for example a new drug or technology).

The new discovery is patented to protect the researcher’s intellectual property so no-one can use it without permission.

The patent is often licensed to a company for production by a document called a licensing agreement.

The company then has a monopoly on the products of the patent and can charge as high a price as they like, even if this is unaffordable for many people in the developing world.

cal treatment. 10 million people are still in need of antiretroviral treatment worldwide . Universities have an important role to play in access to medicines across the world and current negotiations could have profound effects. As the global landscape of pharmaceutical production and distribution changes over the coming years it remains to be seen what effect our generation will have. Beth Sampson, International Health Intercalated BSc Student and Universities Allied for Essential Medicines Coordinator at UCL. Contact; uaem.ucl@gmail. com Download a letter from UAEM to the European Commissioner for Trade at www. uclmedsin.org For more information on Universities Allied for Essential Medicines at UCL visit http://www.uclmedsin.org/uaem.php Further reading: UAEM International Website http://essentialmedicine.org/ Letter to European Comissioner for Trade; ‘concerns regarding the Free Trade Agreement currently being negotiated with India’ http://essentialmedicine.org/story/2010/10/05/uaem-eu-calls-eu-ensure-free-trade-agreement-india-doesnot-hinder-access-medicines Philadelphia Consensus Statement which sets out the aims of UAEM http://essentialmedicine.org/cs Chokshi D. Improving Access to Medicines in Poor Countries: The Role of Universities. PloS Medicine. 2006;3;6;723-6 Chaifetz S et al. Closing the access gap for health innovations: an open licensing proposal for universities. Globalisation and Health. 2007; 3:1. http://www.globalizationandhealth. com/content/3/1/1

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Interested in Access to Medicines in Developing Countries? About 10 million people in developing countries die each year because they don't have access to existing essential medicines and vaccines. Universities Allied for Essential Medicines (UAEM) aims to make medicines and medical technologies developed at UCL available in developing countries. We aim to do this through a licensing agreement that allows for generic production in developing countries. Wouldn't you want the research done at your university by students to reach those who are currently too poor to afford it?

Then come along to the next UAEM meeting email uaem.ucl@gmail.com to find out more.

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Setting the Record Straight

fter 30 years of raising the profile about AIDS, many people still struggle with false myths and misconceptions about the disease. In the last 30 years, attitudes have changed significantly towards HIV sufferers, as people have come to understand that the disease cannot be transmitted by touching, hugging, kissing or even sharing food. Yes, we all know infection with HIV occurs solely by transfer of blood, semen, vaginal fluid or breast milk. However, although much progress has been achieved, there are still many misconceptions that continue to linger in the minds of both public and sufferers. With this in mind, this article aims to dispel ten HIV myths commonly encountered in our day and age. 1. HIV and AIDS, aren’t they the same thing? No, they are not. HIV stands for Human Immunodeficiency Virus, whilst AIDS is the Acquired Immune Deficiency Syndrome. Therefore, AIDS can be described as the collection of symptoms, infections and diseases that can arise as a result of a deteriorating defence of the body’s immune system. However, although HIV can lead to AIDS, an HIV positive individual does not automatically qualify as having AIDS as the virus can remain latent for years. 2. “You can’t get HIV from oral sex.” It is possible to contract HIV from oral sex, where there is contact between semen or vaginal fluid and the mucous membranes of the mouth. Although the chances are much lower than they are with sexual intercourse, the risk is still present and increases with frequency of activity. 3. “My partner and I are both HIV positive, so there is no need to practise safe sex.” This is completely untrue. Firstly, safe sex does not only offer protection against HIV but against many other sexually transmitted diseases. Furthermore, there are different strains of HIV, and practising unsafe sex can lead to a process called ‘re-infection’ whereby the individual acquires a second strain. 4. “I am HIV positive, my life is over.” Fortunately, treatment has come a long way since AIDS was discovered thirty years ago. Although there is no cure against HIV, the effective Highly Active Anti Retroviral Therapy (HAART) treatment allows most HIV sufferers to live a regular life with more or less normal life expectancy, as long as the treatment is adhered to for the remainder of their lives. However it is important to remember that in many developing countries, such treatment isn’t readily available to

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HIV sufferers and infection in such areas is still very much fatal. 5. “I’m HIV positive; I will never be able to have a partner and kids.” It is not impossible to have a sexual relationship once diagnosed with HIV. As long as both parties are aware of the condition and both agree to follow the necessary precautions in order to always practise safe sex for the duration of the relationship. They can also choose to start a family without putting each other at risk. This can be done by artificial insemination. If the mother is HIV positive the risk of transmitting HIV to the child during pregnancy can be reduced to as little as two percent, as long as the necessary medication is adhered to, the baby is delivered by caesarean section and the mother abstains from breast-feeding. 6. “I practise safe sex most of the time, and trust my partner, there is no way I’m HIV positive.” It is important to ALWAYS practise safe sex. Many people have multiple partners during their lifetime, and there are many ways of contracting HIV. Many infected people who have been exposed to the virus are often unaware of this fact since HIV symptoms can go undetected in the person for years. In recent times, it seems people are becoming more casual about safe sex, perhaps because there is a sense that HIV isn’t as serious a disease now that effective treatment is available. This is a very dangerous line of thought. HIV positivity remains a critical condition. Although treatment more or less prevents fatality, living with HIV is challenging. Drug side effects, lifestyle adjustments and social stigma can take their toll both physically, emotionally and socially. Consequently, it is always best to take precautions unless you and your partner are both tested and cleared for the disease. 7. “A mosquito bit me, I could have HIV.” False. When a mosquito bites a human being it does not transmit blood from its previous victim. It is the mosquito’s saliva that is injected into the person and this saliva may carry pathogens for diseases such as malaria. However as HIV cannot be transmitted via saliva, it is not possible to contract HIV from a mosquito bite. 8. “Sexual intercourse with a virgin can cure AIDS.” Though this notion may come as a shock to some readers, in some parts of the world, this idea is in fact very common. The idea of ‘virgin cleansing’ however dates back to the 16th Century, well before the discovery of AIDS. In those days,

it was common knowledge amongst Europeans that sleeping with a virgin would somehow rid the body of sexually transmitted diseases. Sadly, this myth is still alive in areas of the developing world, particularly Sub-Saharan Africa. Sexual intercourse with a virgin, or anyone else for that matter, most definitely does not cure an HIV infection. In fact, it is quite the opposite. Sadly this perverse myth has proliferated the spread of the disease and instigated motives for sexual abuse towards women and children. 9. “Homosexuality and bestiality are the reason HIV exists.” A lot of people honestly believe either one or both of these practices are responsible for the introduction of HIV to the human race. These beliefs are completely baseless. Scientists consider HIV to be a mutated form of SIV (Simian Immunodeficiency Virus), a similar virus present in chimpanzees and African monkeys. The SIV most likely crossed over to human beings when these monkeys and chimpanzees where hunted for food and their human hunters came into contact with infected blood. In the past, however AIDS has been associated with homosexuality and drug addiction, which were both largely labelled as the main vectors of transmission, and in doing so overshadowed other historically important contributors such as heterosexual prostitution, and use of contaminated blood transfusions and needles within medical practise. 10. “It’s too much hassle. I’d have to go out of my way to get tested for HIV.” In a country as developed as the UK, where government healthcare is free for all, it couldn’t be easier to get tested for HIV. There are various facilities available which offer free HIV testing. These include sexual health clinics, GUM clinics, some GP surgeries, some contraception and young people’s clinics, antenatal clinics, local drug agencies as well as Fastest clinics which are rapid testing clinics run by the Terrence Higgins Trust . With all these options, testing is easily accessible, confidential and the actual procedure involves a simple blood test. To conclude, there is still much education and awareness that needs to be accomplished in order to address all the myths and misconceptions that often surround a global disease such as AIDS. In order to eradicate the heavy load of stigma and ignorance it carries with it, we must persevere in challenging ideas and changing mentalities. The fight to put an end to AIDS continues. Julia Darko Second Year Medical Student

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Heidi Larson

Medsin Co-president Isaac Ghinai talks to the Executive Director of aids2031. Heidi Larson is the Executive Director of ‘aids2031’, which published the book “AIDS: Taking a Long Term View” this year. She is also a Senior Lecturer at the London School of Hygiene and Tropical Medicine, Associate Research Professor of International Development at Clark University and a Research Associate at the Harvard Centre for Population and Development and Chatham House Centre for Global Health Security. Dr. Larson has served as a senior adviser to the UN and other international organizations on a number of public health issues, including AIDS and TB.

Is there a place for more national and regional action on this, or is this a problem for the international community to address? It is increasingly important for each country and community to recognize its own unique epidemic. AIDS is different in the Ukraine than it is in Uzbekistan. Local decision makers need to know where the virus is and where it is going. And to facilitate this, our response needs to incorporate strengthening research capacity of developing country institutions and improving leadership. The international AIDS response needs more local input and ownership.

What is ‘aids2031’? ‘aids2031’ is a long term think tank on AIDS policy; it was formed in 2006. 25 years after AIDS first emerged, and addresses the actions we can take now to shape the pandemic in 25 years time. We recognize that the problem is a complex one, and even our most optimistic projections (without any major technical advances) predict one million new infections per year up to 2031. This is the best case scenario, based on the current response changing, improving and scaling up its efforts; (but) if we continue as we are or if efforts decline, this figure will rise.

And how has ‘aids2031’ influenced the current response? Nowadays, there is much more talk about the wider social, political and economic forces that drive the AIDS epidemic. The Social Drivers Working Group at aids2031 were important in bringing this debate into the public psyche and shifting the minds of policy makers to practical steps to tackle these structural aspects. From this same working group came the idea of a “minimum legal standard” in AIDS policy, allowing harm reduction strategies like needle exchange and decriminalizing HIV status and risk prone practices like homosexual sex, which improves safety.

‘You don’t get beaten up for having cancer, you don’t get refused a visa for suffering from diabetes. AIDS is much more than just health so we should all be interested’. So what is missing from the current AIDS response? Efficiency. We need to do a much better job with the funds we have. Efficiency in terms of which projects we support; many of the people most vulnerable to HIV/AIDS belong to politically sensitive groups – men who have sex with men (MSM), commercial sex workers, intravenous drug injectors – and it becomes easy for politicians to look over these risk groups and invest in blanket policies for the whole population. Yes, we need universal access to sex education, to antiretroviral treatment, but we need to get much smarter with out targeted prevention methods for at risk groups.

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‘aids2031’ also looks at the role of the youth..? Yes, today’s youth will be the leaders in 2031, and the youth represent one of the most vulnerable groups of HIV infections right now. From our Young Leaders summits, some tangible outcomes are having a big effect on the youth of today; last years ‘5% for the Future’ scheme encourages donors to commit funds to youth led initiatives, and the Global Health Corps connects young people across the world to niches where they may be useful in development. Young people also seem to have this unique ability to shout loudly and demand improvements, something we really need. Our work with young people has also changed our outlook. Young people cannot be dealt with as “young people”, they are an incredibly diverse group of individuals with different aims and requirements and this has had an impact on the international AIDS response.

So are you hopeful that we are winning the fight against AIDS? In terms of the history of infectious diseases, AIDS is an infant. We have made huge progress in 25 years in understanding as much as we do about HIV. We have mobilized huge resources and reached millions of people in an incredibly short period of time. But we are just beginning to see a return on that investment, and we can’t stop now. Do you think there is a danger of AIDS fatigue? Definitely, it’s already happening. Donors are getting tired of giving and giving for AIDS. We cannot get complacent, just because the trend in new infections is beginning to decrease, this is not the end of the problem. Remember the 1 million new infections per year? That’s with our best efforts. If donor fatigue sets in, the number will be far higher. And finally, why do you think AIDS is such an important issue? AIDS is to do with health. But it’s also to do with everything else. It has knock on effects in economic development and can destroy social fabrics. AIDS touches nerves in politics, ethics, human rights, society as a whole, media, everywhere. You don’t get beaten up for having cancer, you don’t get refused a visa for suffering from diabetes. AIDS is much more than just health so we should all be interested.

aids2031 For further information visit: http://www.aids2031.org/

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Beyond Behaviour http://www.google.co.uk/imgres?imgurl=http://iolsresearch.ukzn.ac.za/ImageGallery/187/south-africa-miners.

Seeing the bigger picture in HIV policy

South African migrant workers

e all know that HIV/AIDS represents a challenge of unprecedented magnitude. Regardless of statistics, the suffering the epidemic has caused is immeasurable. This severity of the epidemic, combined with the fact that no effective vaccine exists, makes efficient prevention policy crucial. That is why this article will talk about not what HIV policy has succeeded in doing – but about what it has failed to do. There has been a trend of focusing on behavioural change when formulating prevention programs, and to gather a response as efficient as possible there is a need to address the broader, root causes of the epidemic. In the search of root causes When looking at what spurs the spread of an epidemic, it is natural to start by considering the most proximal causes of disease. For HIV, this means exposure to the HIV virus. This is of course the biological reality of transmission, but it is not the only factor that determines who falls ill. In fact, it is more and more recognized that structural factors such as poverty, gender inequality and poor labour conditions all increase the risk of contracting the disease. As poverty often goes hand in hand with being malnourished, it will make you more susceptible to the virus through an impairment of the immune response. But poverty also represents a lack of economic and social empowerment. Studies made on migration workers in Port-au-Prince, Haiti have shown that a lack of economic resources decreases the amount of per-

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ceived ‘choice’ of sexual partner’s people experience. Both women and men in this area felt that having wealthy sexual partners could represent a ticket out of poverty; that they could not really ‘say no’. Economic necessity is furthermore one of the main forces that drive people into sexual labour – putting them in one of the greatest risk groups for HIV. Gender inequality will also affect the spread of the epidemic. If women are in a subordinate position to men, they might not be able to negotiate safe sex. Even something like a poor occupational situation can put you at a higher risk of contracting HIV. Looking at mine workers in South Africa indicates that men forced to work in a high-risk environment, far away from their families are more likely to both buy commercial sex, and neglect condom use – the risk of AIDS simply diminishes in the face of the risks encountered on a more short-term basis. A behavioural policy paradigm These are only a few examples, but they represent connections that are seemingly obvious; the socio-political and cultural context in which a disease occurs, will affect the spread of it. HIV policy has traditionally been working under a ‘behavioural paradigm’, that is, it has focused on ensuring that people make informed choices, choosing protected sex rather over exposure to the disease. The problem with this type of prevention strategy is that certain individuals might be less capable of transforming information into behaviour change. If you are forced into commercial sex work because you are at the risk of starving, you are not in a position where you can negotiate condom use. Behavioural prevention strategies can be very effective in certain settings, but they need to be complemented by programs that create an environment in which behavioural change can occur. History shaping the present Several explanations have been suggested for this focus on behaviour change that has coloured HIV policy. First of all, focusing on behaviour change fits in naturally with a traditional focus on individual freedom and civil liberty in Western countries. During the 20th century, life has become increasingly perceived as an individual strife, and health a goal one can actively either pursue, or neglect. This shifting perception of how we relate to health is likely to have influenced how policy and prevention strategies are written. Another reason is mentioned in Eileen Stillwaggons book, AIDS and the Ecology of Poverty. She describes how or-

ganisations working with family planning were already working on condom distribution in order to impede population growth at the time when HIV prevention strategies were put into practice. These organisations played a key role in implementing the initial policy, and their long focus on behavioural change might have influenced the way prevention programs were carried out. Moving towards a shift in focus In the face of the enormous challenge that the HIV/AIDS crisis presents, I would not want to be solely critical of policies. There are cases where programs aimed at behavioural change have been effective, Uganda being an oft-cited example. Furthermore, there is good reason for optimism, with development plans increasingly mentioning the importance of structural determinants. Examples are the Abuja Plan, formulated by the African Union, as well as the latest UNAIDS policy reports. In the case of the Abuja plan, monetary constraints have left the plan a blue-print without a clear basis for action. This all points towards an increased realisation of the importance structural determinants carry, and also highlight the importance of consequent implementation of written policy, into action. Concluding on a sensitive issue In order to make prevention efforts as efficient as possible, it is important to look back, realise where mistakes have been made, and learn from them. In this article, I have focused on one of the shortcomings of HIV policy; a tendency to ignore the structural drivers of an epidemic. As a Human Sciences student, I am increasingly encouraged to ‘see the broader picture’. At the start of my third year, I am almost starting to get a bit tired of hearing this mantra frantically repeated - just how much broader can the picture actually get? However, whilst carrying out my research for this article, I realised that this motto has been droning on in my tutor meetings for a reason. In the case of HIV policy, examining the broader picture has led to drastic improvements in the management of a pressing illness. On entering the professional sphere, some of us may be confronted with the HIV challenge, so remember; an examination of HIV policy shows the fundamental value of looking beyond a behavioural discourse towards a picture that is, just a little bit bigger. Anna T Schultze Third year Human Sciences Student

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Rationality, Medicine and ADHD

A recent study found a statistically significant genetic contribution to ADHD (Attention Deficit Hyperactivity Disorder), a condition widely thought to be made up or to be caused simply by bad parenting. The study showed that children with ADHD were more likely to have a certain gene than children without ADHD. While the study itself was presented correctly, the way these results were promoted caused much agitation in the media and scientific community. The Wellcome Trust, who funded the study, made a press release stating that ‘ADHD is a genetic disorder’. The same day a Daily Mail article also promoted the study as showing that it would end stigma about the condition. The promotion of ADHD as a genetic disorder led to uproar. The results of the study were dismissed on BBC Radio 4 as ‘massive spin’. The Guardian published an article the next day arguing that this view of the condition was misleading and later on pointed out that only 57 of the 366 children with ADHD had the gene being linked to ADHD. None of this stopped the Daily Mail from publishing an apparently unrelated article the next day, based entirely on anecdotal interviews asking the question ‘Are some children just born bad?’. A few days later, UCL’s very own Steve Jones wrote in the Lancet about how much of the criticism should really have been directed at the reporting of the trial results rather than the trial itself and how this kind of genetics should not be oversimplified. In order to illustrate the point that medicine is not all rational, one could ask why the study was promoted to show a much more solid pattern of causality than was really warranted by the evidence. A major reason for this, I argue, is because of the uncomfortable uncertainty that surrounds conditions like this. The practice of medicine is always thought of as evidence based, yet when the accepted causal basis of ADHD is weak, it is tempting to overhype what evidence there is. This is because there is a phenomenon in the process of medicine that will be

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explored presently. Once a condition is defined in terms of its symptoms, it becomes necessary to determine its causes (its aetiology in scientific terms). However, if a theory about the disease’s causality fails (or is weak in this case) a person will always tend to reject the theory about the disease rather than questioning the existence of the disease itself. Therefore the debate here ends up centred on whether the children are ‘born bad’ or if the parents can be blamed; not on if the symptoms themselves are better explained in terms of the condition proposed, normal behaviour or as part of another condition. It appears as not an entirely rational approach to what is thought of as discipline based on rationality. This can be seen to occur when new behavioural conditions are defined, so that certain behaviours are excused and thus legitimised. It is integral to the interest groups created by this that the existence of the disease is upheld. Even the concept of whether or not certain conditions (especially behaviours) are classified as diseases or as within the boundaries of health can be thought of as a social construct. It is possible to go further than this to find more examples of how normal practice in medicine is often not rational but ideological. The Economist recently published an article discussing the implications of proposals surrounding the new manual for psychiatric diagnosis (the DSM-V). In an attempt to reflect the scientific grey area that surrounds the diagnosis of many conditions, the new manual has taken a more complex and wide ranging approach to diagnosis. Some doctors are wary of this because they see that it may increase the amount of normal behaviour that is considered disease behaviour, thus the manual may ‘do more harm’ than good.

This directly refers to the core principles on which medical ideology is founded – ‘the Hippocratic Oath’. Ultimately, the entire practice of medicine can be seen as, to some extent, ideological because it must be based on the belief that, by intervening in someone else’s body, it is possible for a doctor to make that person’s life better. While many, even most, people would agree that this is almost always the case, it raises further questions. Specifically, how can someone know that someone else’s life can be made better? How can we even define what is better? These questions become an issue especially in cases where the patient’s right to choose and refuse treatment (their autonomy) is reduced, as is considered to be the case with children and with many psychiatric conditions. A parallel can be drawn here with aspects of humanitarian relief work. For example, MSF must base its work on the belief that they have the ability to go into another country and improve the situation there, however that is defined. However, they also take a clear stance that they are a neutral, international organisation with no vested interests. Parts of this policy have been described as a ‘non-ideological ideology’. However, it is clear that, due to the politically sensitive nature of much of MSF’s work, it is absolutely necessary for the organisation to promote this policy. Clinical medicine has no such necessity to deny its ideology and, as has been shown in this article, a wider acknowledgement of the underlying values and beliefs of the discipline would lead to more productive and less polarised discussions. Rahul Bahl IBSc International Health http://upload.wikimedia.org/wikipedia/commons/e/e2/Ritalin_Methylphenidat.jpg

These days it is never difficult to find controversy in medicine over how diseases are defined and caused, particularly in the more abstract field of psychiatry. This article will discuss how much of this controversy is due to an overestimation of how rational the practice of medicine is. Medicine also has truly ideological aspects that, if they were more widely understood, would help to resolve or avoid some of the arguments. Some of the more recent controversies will be used as examples.

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A Problem is Not a Problem When No One’s Watching: The Media’s Influence on Global Health

he title of this article is not meant to imply that everything about humans is external to their being; nor is it to be understood as a philosophical riddle that questions the possibility of unperceived experiences . What is meant by the heading is that the media plays a vital role in informing the public about what is going on in the world, and as a consequence when it is unreported it is unknown. This effect has a big role on Global Health, especially in countries where many of the inhabitant’s health are dependent on the actions by people elsewhere in the world. It is impossible for those countries to receive help without people knowing that they need help. Several questions may arise including why does society give this medium such power or what happens when the power is utilized in the wrong way. But reducing the media’s impact and appropriating its capacity are two different challenges. In order to determine which is the most feasible and beneficial task to take on requires a better understanding of the issues. How does Media Influence Work? There is no doubt that the media can

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have a major influence on the way society functions. With the advancement of technology over the past fifty years this has become more evident. Many of us are aware of the entertainment and advertising impact that the media has, but “a key feature is their agenda setting power”. The media functions as a vital source of information for the general public. Most of us come into contact with some source of the media throughout the day (whether it is a television broadcast, newspaper, internet, etc.), and many of the decisions that we make are a consequent of the information we gathered. Now, I am aware that most of the decisions that we make are based on what we know for a fact, and this is usually acquired by beliefs that we have acquired over time based on our own experiences. We don’t normally change those beliefs because we hear one person say otherwise. That is, if we looked up every morning and realised the sky is blue we do not automatically erase that thought when told by someone else that the sky is pink. However, we may take time out to go see for ourselves if one was giving us factual information. The influence that the media plays in our life is not that it directly tells us “what to

http://blog.newsok.com/television/2009/02/18/adjustments-needed-with-digital-tv-transition/

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think but rather what to think about” . We all have beliefs that we have attained throughout our lives, but we rely on the media to deliver us current news and important information about what is going on in the world around us. What Does This Mean For Global Health? One point to clarify is that when it comes to Global Health the media does not reject the idea that this type of news is important. So why did the fact that 22,000 children died today from preventable causes not make the headlines ? It is the nature of news that makes it nearly impossible for this type of fact to receive media attention. News is typically seen as something that happened today that made the world different than it was yesterday. So if an earthquake, a tsunami, or terrorist plot kills 22,000 children then it appears that the world has altered in a way that is not so apparent when these same amounts of children die from avoidable reasons. Is this a correct way to perceive the conditions of humans? No. Is it the way that many people responsible for this type of coverage think? Unfortunately yes.

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www.uclmedsin.org www.uclmedsin.org 22,000 children dying from preventable causes did not make the headlines today because a similar amount died for the same reason yesterday, and the day before that, and so on.

We need to find a sufficient way to improve utilisation of this medium so that Global Health issues that are often ignored are also covered

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Los Angeles Times , Friday January 15th 2010

There is however a benefit to this that does not outweigh the cost but is often used as a tool to prevent tragedy. When disasters occur in the world (that meets the broadcasting standards for “news”) the media provides people with an immediate awareness of the adversity. As a consequence everyone is donating money to relief funds to aid those who were affected by this tragedy. If a society that is eligible to assist the survivors were to ignore them it will be seen as immoral. Furthermore, if a news program were to not report on the catastrophe it may lose credibility and will no longer be seen as a reliable source for informing the public. The Earthquake in Haiti earlier this year showed us how generous people can be after a tragedy. With widespread media coverage aiding the relief groups they were able to raise over $500 million in just over two weeks after the tragedy . This was great help for a country that was the poorest country on the western hemisphere before the earthquake, but should we should question why no efforts were made to prevent the poor sanitation and contaminated water supplies that were present before the earthquake struck. Why were the media not reporting about the diarrheal illness that accounted for 17% of deaths in children younger than 5 years old or the fact that four out of five Haitians lived below the poverty line on less than $2 a day ? While there was hardly a channel that you could turn to that was not covering the earthquake the day after, ten months later we hardly hear anything about it on the news. Most of the donations promised to Haiti have not been received, and there is little news out there about the recent outbreak of cholera that has hit the country. So while the media can be used to increase awareness about global health issues and serve as a beneficial tool to those in need, we need to find a sufficient way to improve utilisation of this medium so that Global Health issues that are often ignored are also covered.

A Defence for the Media While preparing this article for the magazine I got a sense of what it feels like to be a journalist working around many constraints. There are editors pressing you for to meet deadlines and it is impossible for one to say everything that needs to be said given the inadequate time and space. It is almost frightening to know that people have to do this daily. It gets more terrifying when one understands that the media is under pressure to generate revenue and attract readers. Medical journalism is often seen as inaccurate or speculative because there is not enough space to give the public an in depth understanding of the issues. The writers have to assume that the reader has no knowledge of the subject, and the complexity of the issues cannot be covered on a couple sheets of paper. Before one can place judgement on the media they have to know the constraints that journalists and reporters are working with. Is there anything we can do? It is likely the case that every reader of this article has an understanding that Global Health is important and wants to raise awareness about it. Given society’s reliance of the media this seems to be the most effective way. It will be unfair to the contributors to this magazine to acknowledge that many people are dedicating a large amount of their time to

successfully reach this goal. There are also people who are occasionally allowed to report about a global health in the mainstream media. Each of us can do a greater job in expressing our interest on Global Health. When we read an article in a newspaper, magazine, or internet on these issues that we find interesting we can write to those who produced it and let them know that we appreciate it. Instead of putting the paper down and saying “that was interesting”, we can suggest the article to others. The only way to succeed is with exchange between the media and the public, the “communication of news cannot remain effective if it is a monologue” .

Daniel Fryer MA Philosophy student Further Reading: Find out about those children that are ignored by the media at http://www. unicef.org.uk/ Read Chapter 6 in Joseph F. DiMento and Pamela Doughman book Climate change: what it means for us, our children, and our grandchildren. Check out Dot Earth(blog) available at http://dotearth.blogs.nytimes.com/ To get a philosophical understanding of the issues read Kwame Anthony Appiah’s book Cosmopolitanism: Ethics in a World of Strangers

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First In, Last Out A career with Médecins Sans Frontières

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What can you actively do for global health? This is a question that many people are searching for an answer to; every day we are confronted by newspaper headlines about natural disasters, epidemics and wars. These situations result in populations facing appalling conditions for a long time after the initial crisis, including lack of access to healthcare, inadequate nutrition and very little security. This is where Médecins Sans Frontières (Doctors Without Borders) plays a huge role in establishing both short and long term programmes to assist numerous countries: primarily in the medical sector, but also through the work of other skilled professionals . Enter MSF Médecins Sans Frontières was founded in 1971 by a group of French doctors and journalists who were frustrated by the lack of an independent humanitarian medical aid organisation, and quickly ascertained that MSF would adhere to the basic ethical principles of independence, neutrality and impartiality . The heart of MSF lies in the fact that everyone is entitled to assistance, medical or otherwise. This is regardless of their race or religion, and irrespective of any political connections they may be associated with. After all, is it not a fundamental human right for every individual to have access to basic healthcare? Today, almost thirty years later, it has expanded into a worldwide organisation, with branches in nineteen countries. MSF aid work has taken place in over sixty countries: in areas of conflict such as Darfur; after the earthquake that took place in Haiti; and above all, in places such as India and Burma where much of the population are constantly struggling to survive, lacking in basic needs such as food and clean water. The aid delivered by MSF workers includes surgery and basic medical care in MSF hospitals and clinics, however their long term plans range from vaccination programmes, to continuous treatment of infectious diseases, for example tuberculosis, malaria and HIV/AIDS . Doctors without borders “Working with MSF is what being a doctor is really about – you are literally saving the lives of desperately ill people every day.” Simon Burling, speaking about his experiences working with MSF in Somalia, explains the reasons for which many medical students and doctors wish to work with MSF at some

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point in their careers. Nevertheless, many do not truly understand the reality of working in harsh conditions, with very few comforts, including electricity and running water. More importantly, the pressure of such hard work in these circumstances requires a great deal of professionalism, commitment and flexibility. Yet the rewards and skills gained from working with MSF are priceless: “you’ll walk away with more than you ever gave” . Medical students who wish to get more involved with MSF’s work later on in their careers are encouraged to carry out their electives in developing countries to get a feel for the challenges they may face working out in the field. MSF continues to recruit a large range of medical staff: from surgeons and anaesthetists, to nurses and midwives. Lab specialists with degrees in biomedical sciences also play a huge role in the field, for access to rapid diagnoses in clinics. Doctors who have been specifically trained to treat infectious or tropical diseases, and those with experience in obstetrics and gynaecology are especially sought after . Nonetheless, once abroad, MSF workers may be thrown into situations and medical cases where

they have little previous experience, but learn through the support of their fellow staff and the rigorous MSF protocols. A great deal of creativity is also needed, as doctors attempt to re-create procedures using the only materials that are available to them. A recent development in the work of MSF includes establishing programmes dedicated to those suffering from mental illnesses, particularly for those who have been affected by political conflict or war, which would have a profound impact on them psychologically. Similarly, victims of disease such as HIV/AIDS may feel marginalised and excluded by their families and communities, hence the reason for which MSF has called for more mental health specialists, that is to say, those with qualifications in psychiatry, psychotherapy, clinical psychology and psychiatric nursing . It has recently come to light that many doctors working in the National Health Service in the UK are worried about how developments in the NHS, such as Modernising Medical Careers, may affect their later careers if they do choose to get involved with MSF, since the minimum re-

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quirement is nine months abroad . Some doctors did speak negatively about their experiences working in “stressful, frustrating and demanding conditions” , and 16% of doctors questioned believed that working with MSF had a negative impact on their careers. However, despite this, the majority of MSF workers believe that their missions abroad can be compared to “recharging [their] doctor batteries” , enabling them to gain invaluable skills, understanding and experience. MSF without borders Despite its name, MSF provides numerous opportunities for non-medics to get involved: the programmes would come to a standstill if it were not for the logisticians, financial controllers and specialists who accompany the medical staff. Technical logisticians are wholly responsible for reconstructing hospitals and clinics that may have been damaged as a result of conflict; maintaining electricity supplies in clinics; and organising the transport of medical supplies. Administrative and finance positions can also become available, managing the workers on the camp, and frequently interacting with the local authorities about the ongoing MSF work . While MSF focuses primarily on providing medical aid, they also realise the importance of long-term management.

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A contaminated water supply in itself can rapidly lead to a health crisis, giving rise to outbreaks of cholera that could otherwise have been avoided. Hence MSF also recruits specialists in water and sanitation , particularly those with backgrounds in engineering, to design and build wells and other such water sources, and moreover, to formulate ideas about managing waste management well, particularly close to the hospitals and clinics, to minimise transmission of water-borne diseases. So what can students do? It is not possible for students to work directly for MSF on their missions abroad, owing to the difficult conditions as well as the scarcity of equipment and facilities, and it is for this reason that MSF do not offer electives to students. Nevertheless, in emergency conditions such as the aftermath of the earthquake in Haiti in January earlier this year, some local students were recruited to help the MSF aid workers with their basic tasks . The challenges faced by these students were undoubtedly unlike anything they had experienced during their studies, but the skills and understanding they developed as a result have proven invaluable for their future careers.

numerous universities have established societies where they promote awareness and raise money for MSF. Here at UCL, the Friends of MSF group organises talks, screenings and other events, which are open to everyone, which may inspire you to work for MSF one day. As Dr James Orbinski said in his acceptance of the Nobel Peace Prize on behalf of Médecins Sans Frontières: “independent humanitarianism is a daily struggle to assist and protect… it is lived most deeply, most intimately in the daily grind of the forgotten war and forgotten crisis.” Alisha Allana IBSC Pharmacology Student For more information about UCL Friends of MSF email uclmsf@gmail.com or visit our website: www.msf.org.uk/ucl. friend. Further reading MSF website www.msf.org.uk An Imperfect Offering (Dispatches from the Medical Frontline) by James Orbinski Six months in Sudan: A Young Doctor in a War-Torn Village by James Maskalyk Also see article on ‘Turning passion into action – What students can do for global health’.

The main way in which students can get involved is through ‘Friends of MSF’:

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magine a typical childbirth scene (minus the gory details): a woman in a shiny hospital room, with access to a range of pain relief, hooked up to various monitoring machines, having full attention from her birthing partner, midwife, and obstetrician, and with the knowledge that if anything starts to go wrong, there are a range of procedures available. Baby overdue? Medical induction. Labour too slow? Break the waters or set up a hormone drip. Mother needs a bit of help? Forceps or ventouse. Complications? Caesarean section. Now just compare that with the same scene one hundred years ago: a woman at home in a dirty room, with whisky or chloroform for pain relief, attended by a woman without medical training. Natural childbirth is becoming a rare phenomenon. Mothers are bombarded with choices of drugs, procedures, and technology. The increasing medicalisation of childbirth is clear to see. Of the 700 000 deliveries annually in the UK, it is estimated that less than half could be described as normal. Routine interventions in childbirth include : • artificial rupture of membranes • caesarean section

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The Medicalisation of Childbirth

• • • •

continuous electronic foetal monitoring epidural anaesthesia episiotomy recumbent birthing position

Too posh to push? A recent review of caesarean sections by the Royal College of Obstetricians and Gynaecologists has shown that the rate of caesareans have more than doubled since the 1980s, with it varying between 14.9% and 32.1% between different trusts . Compare this with the World Health Organisation’s recommendation that the rate of caesareans should be no more than 10-15% . The cause of this increase is unclear, but the myth of an increasing amount of mothers that are ‘too posh to push’ and thus have an elective caesarean have been dismissed, stating that there was no evidence to suggest that low-risk women were being given caesareans inappropriately. The Causes? The reasons for the increasing medicalisation of childbirth include:

1. Safety – Childbirth is very risky and happens on a mass scale, so researchers are constantly trying to find ways to make it safer and less painful. 2. Litigation – A large chunk of all litigation against the NHS involves obstetric cases. This has led to an increase in the use of defensive medicine, whereby if a doctor uses all the technology available, they cannot be blamed. Whether this is best for the mother and baby is highly debated. 3. Patient Choice – In today’s society patient choice has taken over from paternalistic medicine, and women often make birth plans to indicate how they want their pregnancy and labour to be managed. Data Trends Over the past century there has been a huge swing from home births to hospital births, with the rates of home births dropping from around 80% in 1920 to 3% today . In the same time period, the outcomes of childbirth have improved immensely in the UK, with maternal mor-

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www.uclmedsin.org tality falling from 400 deaths per 100 000 births to 8 deaths per 100 000 births today . This has lead to the questions ‘is a home birth more dangerous?’ and ‘is the increase in obstetrician led births responsible for the lowering of mortality rates?’ Global View There is no doubt that the presence of a skilled health attendant at delivery is vital. Whilst in developed countries a skilled health attendant assists in more than 99% of births this is only 62% in developing countries . WHO want to increase this as part of the 5th Millennium Development Goal, which aims to improve maternal health. WHO state three main causes responsible for the high rate of maternal deaths in developing countries: severe bleeding after childbirth, infections and hypertensive disorders, which in the majority of cases could be prevented or treated with the right medical care. In developing countries, the rate of maternal mortality is 300 times higher than in developed countries. Worldwide maternal deaths have dropped by 34% between 1990 and 2010 , which whilst progressive, is less than half the rate of reduction that is needed to achieve the goal of reducing this figure by 75% between 1990-2015. The rate of decline of maternal mortality has been particularly low in Southern and East Africa, as there has been little change in numbers of deliveries with a skilled health attendant present, leaving the rate of unassisted births to be as high as 94% in Ethiopia . Common barriers to skilled health attendants at delivery include physical inaccessibility, cost and sociocultural practices. Back to the UK In the UK, lack of skilled health care at delivery is not a problem in either hospital or homebirths. Whilst evidence has clearly shown that obstetrician-led care and medical intervention is important in complicated pregnancies, in normal pregnancies and labour there is a lack of evidence to show its effectiveness. One problem is in collecting reliable data, as women who have home births tend to have: • Low-risk pregnancies • Different maternal attitudes towards medical involvement in birth • Better levels of education • Had more than one child • Had fewer previous obstetric complications (such as caesarean sections) • Lower levels of obesity Looking at these factors together with the small numbers of women who have home births, comparative studies on home birth versus hospital births have been made difficult to achieve. The National Institute for Health and Clinical

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Evidence (NICE) have expressed concern for this lack of evidence of the risks and benefits of home births vs hospital births. They subsequently produced a report concluding that in an obstetrician-led setting vs home birth there is increased likelihood of: • Receiving analgesia • Obstetrical intervention • Delivery using instruments • Less satisfactory experience for the woman • Recovering less quickly It also concluded that the rates of perinatal mortality were equal, provided that there was access to well-trained midwifes, and a good referral system with close access to a hospital. Thus it showed home births to be no more dangerous than hospital births for low-risk women. Home births in the UK In the UK, home births are supported by the NHS, with women having the ‘right to an informed choice’ . The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists support home birth for women with uncomplicated pregnancies. They say that ‘[to have a home birth] may confer considerable benefits for them and their families’. Whilst the rate of home birth in the UK remains low, the past few years has seen a small boom. In the last decade it has doubled in Wales to 4%, although this falls well short of their 5 year target made in 2002 to reach 10% . Many mothers-to-be want a more holistic childbirth experience. This reflects the more general pattern of healthcare, with patients taking back the right to making decisions about how and where they are treated. Home births – a worldwide perspective The rates of home birth vary considerably between countries. In many developing countries home births are the norm, whereas in many developed countries such as the UK the rates are low. In many countries, these rates are related to the legality of home birth. In October this year Agnes Gereb, a gynaecologist in Hungary, was arrested and sentenced to five years in prison for assisting home births. Whilst it is not illegal to have a home birth in Hungary, the Hungarian public health authority, ANTSZ, refuse to issue licences to independent midwives. This has left a situation where women wanting to give birth at home do so in an unregulated environment, with the midwives assisting facing jail for breaking the law . Many other countries such as America, France and Czech Republic have laws or policies that make home birth difficult; contrast this situation with the Netherlands, where 33% of women give birth at home. The Netherlands have an effective referral and transportation system,

whereby if problems do occur during a planned home birth, they are picked up quickly, dealt with appropriately, and taken quickly and easily to hospital if necessary. Recent data has questioned this, as it has found that the maternal mortality has increased since 1992 , and that perinatal and neonatal mortality is amongst the worst in Europe. Whether this is due to home birth or other factors is not yet understood. Birth centres – a reasonable compromise? Birth centres are midwife-led with obstetricians available on call and are seen a half way between home birth and consultant-led hospital births. Seen to be more women-focused than hospital, many offer water births and complementary therapies such as aromatherapy, acupuncture and massage. Research has shown that most birth centres are associated with positive clinical outcomes and parent satisfaction and facilitate active and normal birth. In Wales a third of low-risk women now give birth outside an obstetrician-led setting, either at home or at a birth centre. Looking to the future Finding the safest and most patientsatisfying childbirth experience is clearly one of the most important issues in healthcare, not only here but all over the world. It is important that women can make an informed choice about what is best for them, whether it be a home birth, at a birth centre or consultant-led in a hospital, and also the degree of medical intervention received. This choice needs to be made without the constraints of illegality, cost or lack of access, with the support of medical staff, and with systems in place that allow for flexibility and whereby the patient’s safety is always the main priority. Whilst it is difficult to say how trends will progress in the developed world, it is hoped that the medicalisation of childbirth will continue in the developing world so that every woman has access to medical care in labour, ensuring that the outcome is best for both mother and baby. Katharine Whitehurst Second Year Medical Student Further Reading: Go to http://www.who.int/topics/ maternal_health/en/ to find out more about how WHO are trying to tackle global problems in maternal health Read more about NICE’s assessment of the benefits and risks of hospital births vs home births here: http://www.nice. org.uk/nicemedia/pdf/IPC-cons-fullguideline.pdf

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Bryan Pearson Editor of Africa Health talks to Adaugo Amajuoyi Can you give the readers a summary of your background So my father was a medical doctor in China, he was born in China. His father was a medical doctor. He trained back in the UK and moved to China in ‘51, and after the revolution there, they were Methodist Missionary doctors and they went from China back to the UK when they were unable to stay in China and went to Nigeria in ‘52. He started working in Ilesa, which was an old campus at the time and they then built up Wesley Guild Hospital which then became part of the Obafemi Awolowo University Teaching Hospital. I lived there until I was twelve. Obviously it was a fascinating hospital, with lots of international happenings, a model hospital in many respects. The work of Professor David Morley, who wrote the seminal Paediatric book, Paediatric priorities in developing countries, is still a major text. [It] followed that my father realised that they had a children’s ward absolutely chock-a-block of entirely preventable illnesses. The Imessi-Ile study came [out] of this, which was the beginning of primary health care in many respects. They demonstrated how using a grade 2 nurse and midwife could prevent most of the illness. Very quickly the population was growing by 9% a year, as a kid I could feel how exciting it was, there was a buzz. They trailed the measles vaccine there. It was a very interesting place to be. I then went back to the UK for schooling, but I was always going back and forth and I remember on October 1st 1960 standing on the roadside watching the entourage of vehicles. They were my earliest memories. I joined Africa Health in 1978 and I’m still there, I wasn’t meaning to be still there. So I bought it from them in the mid 80s, they didn’t quite understand what they’ve got and how to publish a journal when you get very few subscriptions that many people could not afford. It is an interesting and exciting time despite the ups and downs. The number of good friends who used to be correspondents and that are now ministers etc. make it a lot easier to move around and meet the key people. So what were you plans then and have they changed since? No, Africa Health is a review journal, we don’t publish original research, and we have spin off journals, original research peer reviewed publications. What we try

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to be is practical and relevant. Probably, if there’s anyone we are writing for, it is the doctor at the district level who has been thrust into responsibility without much support around and with some resource issues. Who suddenly has to be the ‘jack of all trades’ even though they only been trained in a few areas.

‘Civil society is playing a huge role. People are taking control of their own destiny. It’s empowerment, it’s knowledge and the increasing role of women is finally being properly respected and understood. There’s huge change. Do you think it’s become almost fashionable, this interest in African health? I know that within my year, for example, in medical school we have an option of studying an intercalated BSc in physiology, pharmacology, neuroscience but the number of medical students opting for International Health is ridiculous. It is great that the interest is there but the question is this sustainable? Are you finding that people from the Diaspora who are interested in investing back in home are writing in the review journals and completing research that contributes to health in Africa? Yes, would be the quick answer, but no. Since 2000 the economic growth in Africa has seen a huge change. Finally the middle classes are back in many of the countries, people can have aspirations for their kids in terms of what they can earn locally, in government salaries and in private practice. Something that wasn’t possible before. The quality of life back in Ghana, in Nigeria, Kenya is – if you’ve got a job – the quality of life is far higher than here full stop. I know loads of people in the Diaspora who have returned and who are really loving life away from this horrible, old, drizzly weather in England with mortgages and all that palaver. There has been a huge change. Having watched through the ’80s and’ 90s as we came through those difficult structural adjustment times when health got completely squashed. The renaissance in the last 10 years has

really been really great to watch. In the current issue of Africa Health, the concept of country ownership was discussed by Francis Omaswa, whereby he described that governments need to step up and recognise that they have a duty to invest more in health. With figures of only 8-9% of the average African country’s GDP spent on health, do you think pressures from external governments or organisations should be put on African governments to encourage increased spending on health, or do you think we should be taking responsibility ourselves to help the effort in changing health in Africa? I think it’s going to be pressure from people like yourself who will make governments sit up. Francis is a very good friend, he was the first director of the Global Health Force Alliance. What Francis was frustrated by is how prescriptive the donor agencies can be. He feels we can develop from within Africa. So that’s where his piece is really a heart felt plea for them to just leave us; we can find a solutions to these problems. When primary healthcare started in 1978 it never worked in my personal view because: one, there was no civil society in those days – that’s a huge issue, and two, the doctors never bought into it. And we were in a very vertical, hierarchal society and if the doctors weren’t into it, everything would fall apart, because civil society wasn’t there. Today I think civil society is playing a huge role. People are taking control of their own destiny. It’s empowerment, it’s knowledge and [the] increasing the role of women is finally being properly respected and understood. There’s huge change. This year as part of the Medsin society we are organising a STOP AIDS week, where we have a series of talks, a workshops and events around educating students about AIDS. We hope to re-educate students on what AIDS really means and how important it is to understand that there’s no simple solution. I would like to know your thoughts on the current status and management of AIDS in Africa. A huge subject area. You can almost segment Africa as with HIV, the virus plagued east southern Africa big time, with western Africa, the problems have developed much slower and is less evident. The huge development that’s happened in recent times that we campaigned for within Africa Health was

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Perspectives

www.uclmedsin.org about the CD4 count. At what point do we start treating people? I’ve visited so many hospitals where the point at which the retrovirals were being given was simply too late, so many wards were really hospices. They had to deal with people who weren’t going to get better.

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Then you get in the difficult area with the religious influence. To hear some of the statements is just frightening and entirely regressive. There is a large percentage of charismatic Pentecostal [preaching], a topic that will be in the next issue of Africa Health piece by Prof Shima Gyoh (speaking at the Nigerian Partnership for Health conference in November). We wonder if in some ways charismatic churches are becoming a health hazard. They will not accept a problem and hope for a proper solution. That’s a worry. There are a lot of documentaries on Africa, especially Nigeria, at the moment, such as ‘Welcome to Lagos’. Do you think there is a role for them in educating the lay person to understand the socioeconomic culture and mentality of a nation increasing awareness about where these problems stem from? Yes, it conveyed the spirit and complex society. They encapsulated a most complex society with huge care, huge compassion in many ways despite a system that was not structured. I thought that all the people in my rural bit of Cambridgeshire who saw the show commented positively on how amazing the people were. Those programmes were brilliant. Yes I thought those shows were brilliant, and I feel that more shows like that have a place in educating the social culture aspects of a nation something that is very important in grasping fully before beginning to attempt to address management of a nation like Nigeria’s health system. Another example would be in maternal care, I’ve heard stories that in the past, women who had given birth had their mother come and stay with them for up to a year to support their daughter. There is a binding technique women use to help following the birth. Cultural traditions I feel should be considered before agencies draft up policies on care in the community for women following child birth. You have the solutions there; support and training is all that is needed. Yes and yet TBA’s (Traditional birth attendants) are banned in Nigeria. Kima Owohjobi a fabulous doctor in Aruwah. They are so frustrated that they are essentially training TBAs to cope with maternal emergencies. Reaching out to the people in rural areas and then they

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Malaria: keeping it cool for rapid diagnostic tests Clinical management of complicated MDR-TB cases Improving maternal and child health Does male circumcision prevent HIV infections? Confusion and delirium

With financial support from:

are told when to refer. I’m afraid to say, the super specialties are not happy. And here in lies some of the issues we need to get over. Somehow we have to broaden people’s responsibilities because the teaching hospitals are not touching a fraction of the disease burden. You mentioned earlier Francis Owasma. His group have received a huge contract sponsored by PEPFER funded by President Obama’s presidential fund to do a major survey on the quality of teaching across African medical schools. A big point made last week was that I was suggesting that the African curriculum needs a rethink. It hasn’t been involved in similar changes as in the UK medical schools. In Africa it has stayed the same. And therein lies the problem. This idea of an audit could be something medical students could do on their electives as part of their project. But how do we get in there?

Well I spoke to one of the lecturers at the ICH ( Institute of Child Health), they seem very interested in the electives we could be offering (in Ilsea) and it would be very interesting because: a) there are electives available and b) there are research opportunities too. For students [that are] coming through, it would be great for research, a friendly place for them and with the disease burden there, anything you want to look at, you can look at over there. To read the interview in full visit http:// uclmedsin.org/magazine.php To find out more about Africa Health go to: http://www.africa-health.com/ Adaugo Amajuoyi Third Year Medical Student

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Pakistan Floods

http://goodreasonnews.blogspot.com/2010/08/if-you-go-down-in-flood-its-gonna-be.html

Are we suffering from giving fatigue?

n July this year, Pakistan was hit by intense floods described as “like few the world has ever seen” by UN Secretary General, Ban Ki-Moon [CBS World News, 20 Aug 2010]. Monsoons are known to frequent this area; however, this year, Pakistan was subject to the heaviest rain in eighty years. The flooding has particularly affected the Khyber Pakhtunkhwa, Sindh, Punjab and Balochistan regions of Pakistan. The Punjab region experienced over 200mm worth of rainfall in a single twenty-four hour period [BBC World News: Pakistan Floods]. Giving generously... The table below can be used to compare the details of the Pakistan floods to other natural disasters that have recently taken place, allowing us to gain an understanding of the magnitude of the problem.

It can be observed that the Pakistan floods have affected far more people than the other natural disasters that are listed. Furthermore, the floods have destroyed seven thousand schools and four hundred health clinics, not to mention five thousand miles of road. Cases of the deadly disease cholera have already been reported, whilst just under two million people have become refugees as a result of the flooding [UN News Report: Pakistan floods Aug 2010]. One would think that such misfortune would soften the hearts of governments, individuals and celebrities alike. Indeed, many governments have already donated vast sums of money: some of the big spenders include the USA with $150 million, the UK (US $ 210 million) and China with (US $50 million). Other countries have found alternative ways to make donations: Azerbaijan has sent two planes,

No. of people affected (UN estimate)

Death toll (UN estimate)

Total economic impact (UN estimate)

Pakistan floods 2010

14 million

1600

US $43 billion

Haiti earthquake 2010

3 million

92,000

US $7754 million

Indian tsunami 2004

5 million

Over 230,000

US $ 5.6 billion

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each carrying 40 tonnes of humanitarian assistance, whereas Sudan donated ten tonnes of food, medicine and shelter equipment, as well as a medical team. Angelina Jolie has also played a role in providing aid to the nation, donating $100,000 in order to help the country’s population. Add in the countless personal contributions of ordinary people like you and me, and it would appear that Pakistan has received a lot of help, medically, socially and above all, economically. The Shortfall However, despite the aid that has been received, the donations are insufficient for such a large scale disaster. As of about ten days after the disaster, the total amount of contributions from the international community was only a tenth of the initial $460 million aid that the Pakistani authorities calculated the country needed in an emergency such as this. What could be the cause of such uncharacteristic financial caution by the rest of the world? In addition, has the aid been fairly distributed? Some observers for example, Association Press (an American News Agency) Correspondent, Nahal Toosi who has conducted an in depth analysis of the scenario, has concluded that donations have been lower than expected due to the surpris-

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www.defence.pk/forums/general-images-multimedia/68857-images-floods-ravage-pakistan-6.html

ingly low numbers of people who have died as a result of the flooding. Other reasons may include a shortage of media attention towards the flooding when it initially took place, and perhaps a lack of celebrity involvement to promote donations forming a dilute international response. Other commentators such as Dr Marie Lall, Pakistan expert at the Royal Institute of International Affairs (Chatham House) and senior lecturer at the Institute of Education argues that there is “donor fatigue all round” with a high intensity of natural disasters happening during an economic recession; people are running out of money and are tired of giving. David Cameron’s comments that Pakistan could not continue to “look both ways” in terms of receiving aid from Western countries, while trying to “promote the export of terror, whether to India or Afghanistan or anywhere else in the world”; can be seen to have further damaged relief efforts. [The Express Tribune, 13 Aug 2010]. These associations have been greatly denied by the Pakistani envoy to the United Nations, who claims that it could negatively influence the generosity of the British public. Furthermore, the behaviour of the President has also been fairly controversial: he only visited some flood areas two weeks after the catastrophe had occurred, yet made state visits to Britain and France. Such displays may have led the international community to think that the situation in Pakistan was not as dire, as it had first appeared. But now let us turn our attentions to what has been achieved with the aid that has been given thus far. So has aid been effective? There have been reports of looting and attacks on aid convoys by the Pakistani people, because of a disorganized system of aid distribution. There were also allegations that rich landowners and members of the ruling political party have also been directing floodwaters away from their own crops onto the lands of defenseless villagers [BBC World News, Pakistan Floods]. Owen Bennett a former BBC Pakistan correspondent reports that during the Kashmir earthquake of 2005, the army was recruited as reinforcement to assist in aid distribution. However, they are currently involved in political conflict with the Taliban in the north-west of the country. This has left Pakistan vulnerable to exploitation by Islamic groups such as Lakshar-e-Taiba, who are keen to take control whilst the government is struggling to distribute aid. Fortunately, no such political takeovers have, as yet, been reported.

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Therefore, careful to ensure the aid has been given to the right hands, many international governments have shied away from government-to-government transactions and have directed the funds through non-governmental organizations such as Oxfam. Yet this means that there is a smaller impact on the international field and creates tension between the NGOs and the Pakistani government. Not giving is not an option The short-term effects of the flooding are evident, but the long-term effects to the economy, land and health of the nation will be even more devastating. We must try our best, on an individual and a collective level, to ensure the optimal physical and emotional well-being of the people affected by this natural disaster, right now, in order to prevent the future creation of a state which is weak and ineffective, that in turn produces a generation which is disempowered and bitter. Despite the political wrangling going on

behind the scenes, we should never forget that this disaster has a human face. Many other countries with questionable governance have been affected by such disasters, but they have not been chastised to this extent. It is true there have been a large number of natural disasters in a financially insecure period but if we were in the same situation, we would want all the assistance possible. Let us not deny that basic right to the innocent Pakistani population, who have been caught up in this political drama. We need to summon the motivation to be generous with our time and resources once again and overcome this ‘Chronic giving fatigue’. Iheoma Okpala Final year UCL medical student For more information See Asad’s blog ‘Welcome to Jamshoro’ To make a donation https://www.oxfam. org.uk/donate/pakistan-floods

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Welcome to Jamshoro

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fter a rollercoaster journey along the Pakistani Highway, we came to an abrupt stop at a check point thirty minutes before schedule. Tariq, the relief co-ordinator of Indus Foundation Trust, stepped out of the jeep and carried out a quick register before engaging in a deep discussion with the local police. “Where are we?” I asked Asim, the driver, as I looked around and acknowledged the empty surroundings. “Welcome to Jamshoro sir” replied Asim, as he closed his eyes for a well deserved nap. Driving in Sindh is a difficult art and the four hour journey on some treacherous roads had clearly taken a lot out of Asim. Jamshoro - a place I had never heard of but certainly now will never forget. Once a vibrant city, its close proximity to the Indus river provided fertile land for agricultural production. Land that was once rich with vegetation, is now reduced to nothing with not even a tree in sight. Jamshoro, once known to be the biggest educational centre in the Sindh province, being home to a number of universities, is now left vacant. The universities that once produced doctors, engineers and lawyers, are now closed down and house many of the flood victims. Tariq returned to the car with a worried look on his face. Security was on high alert and a protocol had been set up to ensure relief goods were distributed in a safe and secure manner but the truck of supplies was running late. Aid in the form of survival packs reach these remote camps every few weeks but there are never enough supplies to provide the 1,000s of displaced refugees that are dispersed around Jamshoro (and this story is retold all over flood affected areas). The truck finally arrived and after the driver was sternly questioned as to why he was late, Danial and I jumped onto the back of the truck as we made our way to the first camp escorted by the local police. The truck contained 300 survival packs, about 20kg in weight, put together by the Indus Foundation. Each pack contains food, medicine and materials to provide a family subsistence relief for 3 weeks. A starving man who no longer has the basic necessities to live, who is on the verge of losing his sanity will be prepared to do anything to get his hands on a survival pack. As we pulled up to the camp, a young man by the name of Faisal rushed over to us. Faisal, an 18-year old student on leave from school, lives in the camp alongside the refugees and is in charge

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of the relief operations in Jamshoro. He quickly warned us that many looters from nearby cities as well as unregistered refugees from other camps would try and get hold of the survival packs. Before he could finish, hundreds of refugees spotted our truck and ran towards us screaming and shouting in despair. Tariq and Faisal tried to restore some order amongst the crowd who were clearly in desperate need of aid. Faisal began to speak to them in Sindhi, the local dialect, explaining to them only those who are registered would receive aid. He began to shout out those registered names but his voice was muted by the deafening noise of the crowd, resulting in the local police intervening to quieten the crowd. As he shouted each name, that individual rushed forward to the truck frantically waving his identity card as if he was holding a winning lottery ticket and was given a survival pack. The others anxiously watched and some started to pray loudly, fearing their name would not be called. We ended up distributing most of the 300 packs at the first camp, with the remaining to be delivered at another nearby site. As we started to drive away, the crowd seemed to have grown and followed. As the driver applied a little more speed, many started to run bare foot pleading with us to give one last survival pack. A mother holding a baby gave up on the chase and instead put her hands together, begging a last plea for a pack. Tariq, who was in a jeep ahead of the truck, phoned us with strict instructions to keep going despite the chase of the refugees. However, the plea of the mother hit us hard and Faisal asked the driver of our truck to stop. In hindsight, this was probably not the brightest idea, but our conscience beat our sense of security concerns. As the truck came to a halt in the middle of the road, looters turned up on motorbikes and ambushed our truck, trying to get their hands on scarce supplies. A few managed to get inside the truck where Danial, Faisal and I were standing but luckily the local police turned up just in time. The police, however, could do nothing to stop the horrific scenes that unfolded in the distance as we drove off in the empty truck. Elderly men and women were being thrown across the street as the refugees and looters faught for the last few survival packs. It felt as if we were in a warzone where ‘every man for himself’ was the only way for survival. The empty truck stopped at a check

http://pakistanifloodrelief.wordpress.com/information/statistics-2/

Written on September 18, this is taken from a blog written by a UCL student who spent the latter part of his summer volunteering in Pakistan following the Flood Disaster.

point where Tariq awaited us. He seemed angry at first for not following his orders but then sympathised with the situation we were in. After making sure we were no longer being followed, we said our goodbyes to Faisal and jumped into the Jeep to make our way back to Karachi. There was a strange feeling in the car as we all sat in complete silence each reflecting on such a dramatic day. Although we had provided upto 300 families with aid, we left with a great sense of frustration not being able to provide for more. Since the trip to Jamshoro, I have been in the process of recovering. The day’s intense heat and humidity left me severely dehyrdated and I was forced to spend the night in hospital with an emergency drip. It was by far the most physically and mentally draining task I’ve ever had to do. The images of sheer desperation that I witnessed continue to haunt me. Words truly cannot express the dire situation that the floods have left but let us hope that through our donations, organisations like Indus Foundation Trust and Karachi Relief Trust continue to provide much needed help to the millions of people that have been affected by the worst humanitarian disaster in recent history. Asad Husain Final year Economics student For Further Information see www.indusfoundation.com and www.karachirelief. org See also related article ‘Pakistan Floods: Are we Suffering from ‘Chronic Giving Fatigue’?’

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40% of ADHD children have at least one parent with ADHD There are an estimated 3â&#x20AC;&#x201C;5 million cholera cases and 100 000â&#x20AC;&#x201C;120 000 deaths due to cholera every year

26,262 diagnoses of AIDS and 111,922 cases of HIV in the UK (as of June 2010) Africa has over

News in numbers

million AIDS orphans.

An estimated 100 to 140 million girls and women worldwide are currently living with the consequences of FGM.

The home birth rate dropped from 2.9% in 2008, to 2.7% in 2009 1823, the year of the first edition of the Lancet, a big year for medical journalism November Issue 6

Around 30,000 babies have been born by IVF in the UK alone

In developing and transitional

countries, 9.5 million people are in immediate need of lifesaving AIDS drugs; of these, only 4 million(42%) are receiving the drugs.

3.3 million, the number of MSF employees (including volunteers) Page 23B

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Turning passion into action

Photography by Teddy Hla

What can students do for global health? Reviewing a MEDSIN panel discussion, UCL, 14th October 2010

What can we, as students, really do for global health? This is a difficult question, which must be considered by initially asking: ‘What is global health?’ This cannot be considered without also asking what global health actually is. Through an increased globalisation, spurred by the rise of the internet, financial and political decisions are increasingly made on a global level. This means that events in one part of the world are bound to have a ripple effect in other parts. Global health means health with global rather than national borders; with the involvement of Global Health Policies and Foreign Policy. And a lot of health policies are now written by global bodies spanning these borders. So, as students, what can we actually do? So, how can we play a part in this? According to the panel, here is a quick summary of our roles: 1. Advocacy – for example, specifically campaigning for TB, HIV, maternal health, chronic diseases 2. Mobilising evidence – getting involved in projects, and gathering and analysing evidence. 3. Through policy – e.g one student carried out a critical analysis of the Gates Foundation, which was even published in the Lancet!

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4. Employment/careers – building portfolios for a career in global health. 5. Capacity building and partnerships, taking and creating opportunities – e.g. A good example is an SHO who went to Sierra Leone for his elective and set up an NGO with his friends, which is still running 6 years later. Be creative and enthusiastic Sid Wong (MSF): As students, we’re blessed with time and passion. There are plenty of prospects for advocacy in colleges and universities. Even if you a student body can’t work as an NGO due to the requirement of certain skill sets, you can find opportunities closer to home. You need to be creative and enthusiastic! Here are some examples of ways to get closer to a career in international health: 1. Taking a year out to take a Masters in International Diplomacy/International Health 2. Internships in global health teams or global exchange 3. Travelling to gain an insight into different cultures 4. Learning a new language such as French, Spanish or Arabic 5. Developing important key skills such

as management, leadership and organisation Find your discipline Nina Neeteson (Article 25): Nina studied political science and international development, and then pushed to run education programmes for architectural students in global health. Students are eager to apply their skills to global health and sometimes feel there aren’t any concrete ways of doing this. You just have to be intuitive and show initiative – the field is fluid and you can potentially create your own job and expertise. Nina currently works for Article 25, who provide architectural support for NGOs, they were recently involved in a bid to the Wellcome Trust that examined heat structures within buildings in places such as Delhi. Here the temperatures fluctuate greatly, and the aim was to maximise ventilation in summer and manage heat loss. If you think outside the box, this project has great implications for global health the quality of life in this area. This is just one example of how Nina has applied her passion and skills to work to improve global health. Bringing global health issues to the surface and making global health a prominent feature involves convincing the

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wider community that their skills are relevant to global health. There are many different disciplines with different applications related to health – you just have to find the one that suits you. Examples of the past - Students as key actors David Heymann (WHO): Jeffrey Sachs stated that if a country wants to develop, it has to have a healthy population – this is a message that was taken to advisors of senior members of G8 and heads of organisations. In order to convince these agencies to buy drugs for other neglected diseases, a macroeconomic commission for health was developed. To achive this, senior advisors at WHO organised mass campaigns. These were primarily led by students, particularly medical students, hundreds of which assembled together from all over the world before returning to their respective countries to create campaigns. The students’ activities caught media attention, and their advocacy put pressure on politicians and governments to change health policy. Joining activist movements is one of the

most powerful and important things you can do: student activities in the past were key in adding to the impetus that led to the setting up of the Global Fund. What can students do? 1. Be at the right place at the right time (look for opportunities e.g. WHO internships) 2. Be able to say ‘yes’. 3. Plan: ask yourself ‘where do I want to be in 5 years time?’ 4. Pay your dues (learn about what is going on in the world, build your skill set appropriately, get the right qualifications, experience the world etc.) Challenge inequality Johnny Currie (Former president of UK Medsin) Huge amounts of funds are now available for global health, which must be responsibly distributed among those who need it. One of the most important global health issues right now is inequality, inequality in both knowledge and power. Knowledg e, both newly created and established, is fundamentally unavailable in most areas of the world. Inequality is

not tolerable or acceptable - let’s challenge it. Universities are institutions of knowledge and rightly involve students in campaigns. To successfully get involved, you must: 1. Get your story straight – you must be informed about current and past issues, have facts, and be able to talk to people about them. Discover your personal story: if you know the exact reasons why you want to get involved, you will be able to influence and inspire others. Exploit your emotional connection with these issues – why do you want to make a difference? 2. Surround yourself with like-minded people – “one person is an individual, 2 is a group and 3 is public opinion”. You cannot do things alone, hunting in packs through forums and networks is vital. 3. Have a strategy – Be informed, be engaged. Medsin has the motto “education, action, advocacy”, all of which are necessary to make a change. In creating your strategy, make sure to use your head, heart and hands, be informed, be passionate and get involved. 4. Most importantly, be radical and be revolutionary! Don’t look back and regret never doing anything. To have any influence on global health as students, we need to be educated, informed and pragmatic. We can put pressure on governments to influence initiate change, and we can be proactive now with respect to our own careers, whether they will be directly implicated in global health or otherwise through which we might play a more direct role in global health. We’re at UCL, in London, surrounded by diverse and dynamic global health researchers, speakers, and activists. Let’s use this to our advantage. Cam Wratten & Mandy Shoa Third year Medical Students

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Reviews

The Day I will Never Forget Directed by Kim Longinotto

Africa United (2010) Directed by Debs Gardner-Paterson

runaway girls granted injunctions against the communities that are trying to circumcise them. It presents a major step towards these ‘disobedient’ girls creating a new culture for themselves, where they can pursue their education and make their own decisions. Utterly fascinating, yet at times hard to watch. ‘The Day I will Never Forget’ is a piece of cinematic excellence; the Massai music, stunning visuals and poignant narratives ensure that all aspects of the multifaceted issue that is female genital mutilation in Kenya are presented to the audience. Without a doubt, a highly insightful and productive 92 minutes. The Day I Will Never Forget is available to watch on Channel 4 on demand.

www.astrafilm.ro/en/international-26

‘I want to tell you a poem, entitled ‘The day I will never forget ’: It was on a Sunday night when my mum called me, and said my daughter come in a low voice. I went quietly. My daughter tomorrow is your ‘D-day’...’ And so the film on female genital mutilation in Kenya begins, with Fariuza, a girl that cannot be more than 10 years of age detailing the day she was forced by her mother to undergo circumcision, which she describes as her ‘crucification’. It is evident from the offset that this film will present some very strong characters, with some highly emotive narratives; wanting to stand up and be counted as one of those to speak out about the implications of genital mutilation. The film goes on to examine the stories of Amina, a newlywed who wishes to undergo a reversal procedure which is later denied by her husband as well as that of Samiola who is forced to run away after being circumcised and married off to an ‘old man’. The most powerful scene comes when a young girl watches her older sister undergo circumcision, and quite unsuccessful struggles to save herself from a similar fate. However, the brilliance in the film lies in the fact it does not simply focus on those marked out as ‘victims’ of genital mutilation but also on the those characterised as the perpetrators. Many of the girls mothers have experienced a similar fate and see the process as a ‘cleansing’ and a ritualistic part of their Somalian and religious roots. But the film is not entirely morose and characters such as Nurse Fardhosa (a nurse who tries to persuade girls not to undergo circumcision and carries out reversal procedures for those that have) displays a progressive attitude and embodies a figure of hope for those girls that seek out an alternative culture. The film concludes on a landmark ruling that sees a group of

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captors. Aside, from the surprisingly unrealistic yet emotive plot some interesting cinematic tools were employed: the main narrative was intersected with cartoons; the figures were wooden and reflective of typical African craftsmanship, all of this based around the young Rwandan boy’s story telling. Ensuring the viewer never forgets that these are children, facing some very real issues. On watching the film, you realize ‘Africa United’ has a multitude of meanings; but for me the most significant is that there is strength in unity: African’s must unite as they did during the World Cup to achieve something great. I challenge you to find a greater meaning.

The film ‘kicks off’ quite unexpectedly with a young Rwandan boy, teaching the seemingly ignorant audience how to make a football African style; i.e. with some rubber, some string and a blown up condom. It seems silly, but it’s not; exactly how the film appears on first inspection. Five youths travelling unaccompanied across worn-torn eastern Africa to reach the monumental world cup in South Africa. ‘Highly unrealistic’ I hear you cry, yes, and that was me until I took the time to watch the film. ‘Africa United’ manages to remind the audience about Africa’s troubles, yet still maintains that there is hope and a means Annabel Sowemimo of progression there. The World Cup in South Africa this year Perspectives Editor displayed some of the passion and vigor that Africans have to share with the rest of the world (if not simply angering others with the overwhelming sound of the vuvuzela), whilst providing news coverage for the multitude of issues the country has faced post-apartheid. The film does a decent job in providing the audience with a layman’s introduction to some of the issues of that threaten this region, through some fairly stereotypical characters: the child soldier that seeks to turn his life around, the child prostitute that runs away, the middle-class kid who does not wish to be a doctor, the poverty stricken kid who wants nothing more than to be a doctor...but I’ll have to leave some out, I don’t want to be a spoiler. However, these stereotypes are not to be scoffed at as the movie manages to delve into a series of complex issues that culminate in some tense scenes; one of the best being the fight scene between the ‘deserter’ child soldier and his

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November Issue 6 B

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Perspectives

Calendar 27th November

29th November4th December

30th November

TEDX EUSTON : ‘Our Destiny in Our Hands’ Time: 12pm - 8pm Venue: Jeremy Bentham Room, University College London Speakers: Richard Dowden, Hanah Pool and others Medsin Stop AIDS Week Monday – An evening with Silvia Petretti. 7:30pm, Cruciform LT1 Tuesday - Stigma and HIV. 7.30pm, Darwin Lecture Theatre Wednesday – Trafalgar Square Flashmob. 2pm, Wear Red! Thursday – The past, present and future of HIV. 7.30pm, Christopher Ingold Auditorium Friday - MSF Film Screening. 7.30pm, Cruciform LT2 Saturday - Sexual and Reproductive Health Campaigning and Advocacy Workshop. 10am-4pm, Wilkins Haldane Room For more details visit stopaids.medsinucl.org Lunch Hour Lecture: Can HIV treatment stop the AIDS epidemic? Time: 1pm Venue: Darwin Lecture Theatre International Institute for Society and Health & Institute for Global Health 2010 Public Seminar: Social determinants of health in adolescents Time: 5pm - 6pm Venue: Roberts 508 Lecture Theatre LSE IDEAS and Africa Talks public lecture Africa and the World: the view from Washington Time: 6:30pm - 8 pm Venue: Old Theatre, Old Building LSE

1st December

The Hon Mike Rann CNZM MP, Premier of South Australia and Minister for Sustainability and Climate Change Time: 3pm - 5pm Venue: Cruciform LT1

3rd 5th December

EuWHO: The first European simulation of a World Health Assembly Admission: register at http://www.rsm.ac.uk/EuWHO/index.htm

19th January

November Issue 6

Ecocide: the 5th Crime Against Peace - a law to prevent the destruction of ecosystems and protect global health Time: 3pm - 4pm Venue: UCL Institute of Global Health

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