Issue 7 - UCL Medsin Perspectives Magazine

Perspectives

UCLU Medsin’s RUMS Society’s Global Health Magazine The Gender Equity Issue

Perspectives

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Letter from the Editor This Perspectives centres on Medsin’s Gender Equity Campaign, whether you are thinking ‘Why Gender Equity?’ or ‘I know everything there is to know on Gender Equity’; this issue has something to offer you. Addressing Inequalities in Women’s Health provides an enlightening overview of the key problems and policies surrounding women’s health.

Our writers have worked hard this term to bring you important, but not necessarily widely publicised issues such as the increasing cases of breast cancer in the African continent - Breast cancer in Africa: an emerging epidemic-displaying how globalisation and westernisation are changing the concerns of women’s health. This theme is keenly displayed in Plastic Surgery, the Brazilian woman’s power suit? This shows health as a multifaceted field where socio-economic and political factors can have important implications.

However, the Perspectives team would not like to give the impression that issues of Gender Equity are limited to distant continents. Perspectives spoke to Silvia Petretti from Positively UK who highlighted that here in the UK, women are still struggling to have their health rights acknowledged; we do not need to look beyond our own doorstep for Gender Equity causes that need more advocates!

If after reading Perspectives you are feeling a bit restless, then we have achieved our aim. If you wish to engage further with international health topics then check out the Events Calendar or purchase the Immortal Life of Henrietta Lacks (the book reviewed for this Perspectives).

Finally, we hope to see you at the Medsin: Gender and Health Panel Discussion on Tuesday 15th March 6pm, Sir Ambrose Fleming LT (G06) Roberts Building (followed by a reception in the Roberts Foyer).

Annabel Sowemimo Perspectives Editor

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Contents

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Current Affairs

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Letter from the Gender Equity Campaign

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Why Gender Equity?

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Breast Cancer in Africa

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Plastic Surgery in Brazil

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Domestic Violence and HIV

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FGM and it’s medicalisation

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Addressing inequalities in Women’s Health

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Congenital Lymphangioma

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The Importance of Emergency Mental Health Care

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News in Numbers

20

Reviews

21

Your Views

22

Calendar

Cover Photo from: www.chenglita. wordpress.com/ 2010/10/13/58/

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The Team Chief Editor Core Editors

Head Designer Proof Reader

Webmaster

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

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Current Affairs On February 22, Christchurch, New Zealand was struck by New Zealand’s most deadliest earthquake in almost 80 years, killing 148 people and injuring a further 2500 people. Measuring 6.3in magnitude it caused unanticipated disaster, causing mass destruction to the cities buildings, roads and bridges. It is estimated that 2000 people have been displaced and the current death toll has risen to 163 people, but police have stated that it is likely to reach 240. New Zealand Ministry of Civil Defence, John Hamilton stated on 3rd March that they had given up hope of finding any more survivors.

www.vosizneias.com

New Zealand struck by Earthquake

The Red Cross has been working hard with the local community to meet their needs by setting up welfare centres and organising food distribution. Call centres have also been established, already receiving more than 400 calls to help establish family links. It is estimated that nationals from over 20 countries have been affected, displaying how the effects of a natural disaster can be incredibly far reaching.

Libya’s Refugee Crisis www.totallycoolpix.xom

Following the violent clashes that have erupted following Colonial Gadhafi’s refusals to ‘step down’ as Libyan leader, it is estimated that more than 70,000 people are now stranded on the Libyan-Tunisian border after travelling for days, mostly migrant workers from Egypt. With the International Organization for Migration stating that almost 200,000 people have now crossed from Libya into Tunisia, Egypt and Niger. The mass exodus has heightened as violent armed clashes which brought the country to a standstill have now turned into a civil war.

The situation in Libya has now become a humanitarian crisis and most be dealt with as such and governments must take action. To help deal with the crisis, Europe, the United States and the United Nations were donating more than $30 million. NGOs such as the International Red Cross have been in the centre of the action trying to support those that are unable to leave but much more help is needed. The Tunisian army and the UN have set up transit camps for some that are able to cross the border, but many families are without their belongings and sleeping rough.

Visit http://www.redcross.org.uk to make a donations or learn more.

www. genevalunch.com

Annabel Sowemimo

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Perspectives

Letter from the Gender Equity Campaign This academic year has been a spectacular achievement for all those campaigning for gender equity at UCL. Countless talks, panel discussions, film screenings, marches and even plays have been dedicated to analysing gender norms and inequalities, and how we as students can help lead the way towards equity. The Women for Women International group has finally became an official union society, and UCL Medsin have proudly launched our newest campaign: the Gender Equity campaign.

The aim of our campaign is to create a forum for London students to discuss what challenges remain to achieving gender equity, and how they can be overcome. We hope to engage with students from all backgrounds and departments, and consider as a team how we can tackle this often neglected issue in ways that are innovative, powerful and above all – fair. In this way, we hope that the future great thinkers in fields such as health, politics, science, technology and development, will raise gender equity higher on the agenda.

So what challenges are we still facing on the road to gender equity? This edition of Perspectives highlights some of the key issues that the international community have recognised.

But they are just the tip of the iceberg. Gender inequities create challenges in all aspects of health: from service provision and delivery, to care-seeking behaviour, to access and eventual outcomes. Exacerbating this is the vast evidence indicating the particular vulnerability of women living in regions affected by conflict, famine and poverty. According to Childline, in South Africa a girl is more likely to be raped than to learn how to read. The statistics are startling. It is internationally recognised that against such a backdrop, the Millennium Development Goals cannot be achieved without tackling gender inequity.

When asked whether he was a feminist, David Cameron famously replied “Er, I don’t know what it means anymore, but I suspect probably not.” Almost equally disheartening were the concerns of Professor Carol Black, former President of the Royal College of Physicians, who warned that the professionalism and status of medicine would be “downgraded” by the rise in number of female doctors. Evidently, there are still vast gaps that need to be bridged domestically as well as internationally.

The UCL community should be proud of the steps we have taken in recognising these challenges and bridging these gaps. This edition of Perspectives is testimony to our achievements. But there is still much more we can do. If you would like to find out more or get involved in our campaign, please email genderequity.ucl@googlemail.com Neda Taghinejadi Gender Equity Campaign Co-ordinator 2010/11

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Why Gender Equity?

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s gender equity a justifiable goal, worthy of pursuit by society? The arguments used to support gender equity in high income countries tend to be vastly different to those used in low and middle income countries. Distinctly, different measures are used to judge nature, levels and determinants of inequity in different settings. Sometimes these different justifications do not yield the same solutions to the problems of inequity and these differences are the route of disagreements around issues of gender equity. To explore this implies a deconstruction of the concept of gender equity or, more specifically, why gender equity is valuable for a population and a consideration of the merits and drawbacks of different value systems.

to ‘promote gender equality and empower women’ is widely accepted not only as a worthy goal in its own right but as a means to achieving the other aspects of development.

So why is gender equity valuable?

Article 1 of the Universal Declaration of Human Rights states that ‘All human beings are born free and equal in dignity and rights’. If this is accepted, then inequities reflected in rights and outcomes stemming from differing characteristics among humans must be unjust. This is the more likely argument to employ in a high income setting, where few would explicitly disagree with the sentiment of human equality and where limited societal resources or government capacity would be less of an excuse for inaction.

The reasons given recently in The Guardian for continued action on gender equity in the UK were that women still “earn less, own less, have worse jobs, and will suffer more in the recession than men”.

Such inequalities are worthy of action as they may be a reflection of how women’s equal rights to men (supposedly guaranteed by national law) may well be partially illusory in British society. If such equal rights truly existed, these inequalities would not be seen, or so the argument goes. This interpretation of gender equity can be seen in practice as a rights-based view and it fits neatly into libertarian theories of social justice as

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famously constructed by Robert Nozick and others.

either a lengthening of leave for men or a shortening of leave for women.

The second reason is that gender equity is important because it has other positive outcomes, such as improved population health or economic development.

This reasoning presents the achievement of equity as a means to achieving other goals, and not only as an achievement in its own right. It is a style of reasoning more likely to be employed in low and middle income settings where some (including women) may explicitly or privately disagree with the sentiment of equality between men and women.

Low and middle income settings are also where arguments predicated on the goals of improving health or development are likely to resonate among policy makers.

These actions would, however, be in conflict with a consequence-based approach to gender equity. With this approach, it could be argued that, seeing as women are actually pregnant when requiring parental leave there are good reasons for them to have the right to more leave than men. This is because the consequences of not doing so would either be genuinely distressing for the health and welfare mothers and children (shortening leave for women) or a n un-

The third millennium development goal is to ‘promote gender equality and empower women’ and it is widely accepted not only as a worthy goal in its own right but as a means to achieving the other aspects of development. This interpretation of gender equity is more consequential and fits with the tradition of utilitarian social justice famously constructed by UCL’s own resident spiritual founder Jeremy Bentham. Under Bentham’s reasoning, the most just decision was that which achieved the ‘the greatest good for the greatest number of people’ as the wall of UCL’s Jeremy Bentham room declares. By this reasoning, gender equity is a just way to move because of the wider benefits to society.

It is rarely necessary for someone in support of gender equity to have to choose between the two reasons presented here as they are not usually mutually exclusive. They can be seen more comprehensively as the intrinsic and extrinsic reasons for valuing gender equity. Those that promote gender equity can then be glad that various reasons can be given for why it is important. Nevertheless, there are situations where these reasons can be interpreted to give different answers to the same question.

Different answers to the same question?

A simplified, hypothetical case would be the question of how much parental leave to grant to men and women. Taking the reasoning of equal rights, it could be argued that this legal right should be equal. This is not the situation that we see today in the UK where paternity leave is shorter. Therefore the logical end to this interpretation would require

necessary hindrance to businesses (lengthening leave for men).

Therefore, because the needs and situations of aspiring parents are different due to gender, it would be considered just in this interpretation to allow more parental leave to women than men.

There are, of course, other ways to interpret the two philosophies presented here. A rights-based view could feasibly incorporate unequal rights for unequal need, for example. This is only an illustration of potential conflict and the further myriad complications of coming to justifiable pol

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it sees in the world; pragmatism in its rhetoric is a fair request.

Variety in Vision

‘The way gender plays out in society means that women still gain a lot of status from being in a relationship or having children’ from a standpoint of promoting gender equity. Dilemmas like this lead us inexorably to specifying exactly which inequalities one considers to be wrong.

These may be inequalities in outcomes, for example disparities in male and female literacy rates, or in rights, such as the right to a primary education among others. Prioritising these inequalities differently could potentially give you different answers for the best use of public resources.

The power of persuasion

icy lie far beyond the scope of this article.

Women in the world face many evils, ranging from the explicit horrors of outright violence to implicit and disempowering traditions. Many of these stem from the beliefs of and actions taken by those who have no problem with what we would call inequity. Part of the process of improving the situation must be to influence such individuals and groups to believe differently. Therefore, the value of different interpretations of gender equity should also be considered in light of their ability to persuade others.

The same exercise can be applied to find the grey areas in other issues of gender equity.

For example, how should a low income country distribute its resources for the primary education of boys and girls? Should they be geared more towards girls as they may face greater obstacles to literacy (assuming such a distribution could overcome such obstacles)? Or should resources be distributed with no such consideration so that boys and girls ostensibly have equal access to public resources? To answer these questions is not straightforward, even

It is hard to see the value of a rightsbased approach in convincing someone who disagrees. Such an approach would essentially amount to the statement of one’s position: ‘you should change your behaviour because men and women are equal’ to which the reply would come ‘I disagree’. A consequential approach would here be more likely to bear fruit in that, one could appeal to the values of those to be convinced rather than to one’s own values. A community may begin to change its mind about the importance of female literacy if the links to reducing infant mortality are used as a reason. The potentially beguiling nature of explicitly not using one’s own beliefs as a good enough reason may grate on the nerves of those who believe strongly in equal rights. I would make the case that if the intention of a gender equity movement is to change the situation

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I have indentified two distinct reasons for why gender equity is important and begun to evaluate their likely outcomes in different circumstances. They can be thought of broadly as a rights-based view and a consequence based view of gender equity and both are seen in discussions of the topic. Differentiating the two types of reasoning seen is useful in helping people to consider why they support (or indeed oppose) gender equity. Moreover, they can be considered in relation to how they might set policies differently and their different strengths in persuading others. Ultimately, the intention of this article is not to change the beliefs of the readers. However, I hope to enhance discussions and debate around these issues, specifically for these to happen with a greater comprehension of the variety of visions that are possible under the umbrella of gender equity.

Rahul Bahl International Health IBSc Student Further reading I have drawn heavily here on the work of Amartya Sen and his writings in deconstructing and constructing theories of justice. For general considerations of different theories of justice see his book The Idea of Justice or essays Equality of What? and On Weights and Measures: Informational Constraints in Social Welfare Analysis. For a more specific application to gender equity see Nussbaum and Glover’s Women, culture, and development: a study of human capabilities especially the chapter on Gender Inequality and Theories of Justice by Sen available on Google Books.

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Breast Cancer in Africa

An emerging epidemic

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reast cancer is widely recognised as a public health problem in industrialised nations like here in the UK and the USA. Successful advertising campaigns aimed to raise awareness of the risk factors for breast cancer, access to breast cancer screening programmes and the improvement on the treatments available for breast cancer have all contributed to lowering the mortality rates associated with breast cancer.

However, in some parts of the Africa continent and other developing regions, studies have revealed that despite a naturally lower incidence of breast cancer compared to their white counterparts in the West, the mortality rates of Breast cancer in Africa are significantly higher.

There are several factors that contribute to this disparity; advanced stage at presentation, unsupported health systems and even genetic predisposition to significantly more aggressive forms of breast cancer. Other barriers include poor patient awareness and consequently acceptance of breast cancer.

HIV and malaria are still significant problems devastating the continent but breast cancer is not an issue considered a problem in Africa. However, several studies addressing the issue have revealed staggering figures suggesting otherwise. In a study by Anyanwu et al9, of the 664 women who attended the breast clinic in Nigeria, the mean age of presentation was 45.2 years old and the most common age group of presentation was 40-49. Of these women, over 50% of the women waited 6 months before reporting their symptoms to a clinician and up to 37% waited over 1 year. Of the 196 patients with a definitive diagnosis, 72% had an advanced form of breast cancer with stages III/IV. Compared to here in the UK were approximately 70% of newly diagnosed women with breast cancer in North America are in stages 0 or I.1 A similar study in Uganda revealed that the peak age for a women to present with Breast cancer was between 30-39, in correlation with the Nigerian study up to 77% presented in the advanced stage.8 Several studies revealed a disturbing trend of young African women presenting with late stage breast cancer.

This is markedly different to the breast cancer amongst UK women who tend to present with postmenopausal breast cancer often detected early with routine mammography screening.

Westernisation has some contribution to the increase in breast cancer in African women. With an increased demand for education and western lifestyle choice; the delay in age of first full pregnancy and the reduction in time spent breast

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feeding , all these factors are thought to increase the risk of breast cancer. However there are other factors at play.

Biology of breast cancer in Africa There are 4 subtypes of breast cancer, Luminal A, Luminal B, Basal cell-like and Her-2/neu.3 Each are defined by the expression of oestrogen receptors (ER+), progesterone receptors (PR+) and Human epidermal growth factor receptor (HER2). Luminal A and B breast cancers are described as hormone positive as they express both ER and PR receptors. These subtypes of breast cancer are responsive to hormonal drugs like Tamoxifen. The HER2 subtype of breast cancer lacks these ER/PR but there is overexpression of HER2 receptors, targeted by the drug Herceptin. There Basal Cell-like subtype of breast cancers lacks all three forms of receptors and is often referred to as the triple negative subtype. Although studies by Ololadpe et al have revealed that basal cell like breast cancer and the triple negative breast cancer are not synonymous, women with either of these types of breast cancer have a poor prognosis compared to the other forms of breast cancer.

The poor prognosis of the Basal Celllike subtype of breast cancer is due to the aggressive biological nature of the

tumour. It often presents with a high tumour stage, high proliferative index and positive nodal status, whereby the breast cancer had spread to the axillary nodes.

Unfortunately the basal cell like/triple negative form of breast cancer is more prevalent in African women. Stead et al found a 3 fold increased prevalence of the triple negative tumours in African women regardless of their menopausal status. In addition to other factors, these findings explain why African women tend to present with early onset, advanced breast cancer.

With the incidence of breast cancer in African countries like Uganda tripling in the last three decades from 11/100000 to 39/100000, breast cancer should no longer be considered as a western disease or a future concern; instead it should be looked upon as a present day problem affecting women all over Africa.

Challenges faced by Africans in dealing with breast caner Limited resources Funding is one of the main problems as most African countries admit to spending as low as $311 per year on health, so it is probable that a very small amount trickles down to support the oncological health sector. The problem is compound-

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www.uclmedsin.org ed by the fact that Breast cancer is not considered a priority. African countries face a myriad of growing health related problems and medical needs including widespread malnutrition, increasing infant and maternal mortality, and of course the HIV/AIDS epidemic. The recently introduced Nigerian National health insurance initiative has excluded malignancies from its coverage9 displaying a clear lack of interest or denial.

Lack of awareness Misconceptions and unfounded beliefs of breast cancers are also challenges that need to be tackled when dealing with breast cancer. In some parts of Africa, women believe that breast cancer is caused by social misbehaviour such as wearing dirty clothing or putting money inside her bra. In rural areas of South Africa, breast cancer is considered to be a result of a curse or poison sent by a sorcerer.2 Another study involving South African women confirmed that 25% of women from urban areas and 33% of rural areas would initially seek traditional healers to help deal with their breast cancer.

Some societies even approve of men divorcing their wife if she has been diagnosed with breast cancer. Other women fear that after diagnosis her breast will be cut off and she may die.

Many of these women live in rural areas in Africa and without the much needed education on the basics of breast cancer hide their symptoms or simply fall into denial. Such problems contribute to the high numbers of late presentation of the breast cancer where the treatment options if available, become limited.

Even among the more educated African women, breast cancer tends to be low on their list of priorities. In a cross-sectional survey of 204 Nigerian Nurses, 31% were unfamiliar with breast cancer risk assessment and believed that they were not at risk. 1 There is a definite need to improve the awareness of breast cancer and the significance of early diagnosis.

The Action plan There is a number of global health initiatives aimed at addressing breast cancer in Africa including, the Susan G. Komen for the Cure, the Breast Health Global Initiative (BHGI), US Centre for Disease Control prevention, America Cancer Society and the National Cancer Institute.

The BHGI commit to tackle many of the challenges with dealing with breast cancer in Africa. Such aims include the following:• Develop evidence based, economically feasible and culturally appropriate guidelines for under developed nations to improve breast health outcomes.

• Promote empowerment of women to obtain healthcare • Develop infrastructure for diagnosis and treatment of breast cancer • Begin early detection through breast cancer awareness and education

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• Include mammographic screening when resources permit Susan G. Komen for the Cure has provided more than $5.5 million in funds to focus on community organisation education advocacy and access to care including palliative care.

Through the help of the Susan G. Komen for the Cure and the WHO, they form events to educate women and the public about breast cancer and encouraging them to speak about the disease.

The BHGI and Susan G. Komen for the Cure are working in unison with Hope Xchange and Ghana Breast Cancer Alliance to develop and implement educational and training programs. Such programs will hopefully encourage women to seek help early. Their training programme will also involve training pathologists to provide services to facilitate care and provide accurate data to establish a cancer registry.

With a doubt, external aid from such charities and groups will help improve the awareness of breast cancer in Africa.

However, one important group of people are needed to target those women in rural areas afraid to seek for help- community health workers.

Community health workers can play a significant role in improving breast cancer control. As they are part of the community, these workers are uniquely placed to be approachable and accessible to women in their communities who may feel otherwise unable to seek help.

Community health workers can be a source of education, patient navigation and support. As a source of information, community health workers are able to dispel myths and superstition surrounding breast cancer. Women are more likely to approach the community health care workers as they have an understanding of the local beliefs or stigma and will have their own methods of communicating the truth about breast cancer.

Community health workers can be trained to provide clinical breast exams as a form of early detection. They can direct women through the appropriate paths in the health system, encouraging screening, early diagnosis and adherence to treatment all of which are hugely important in successfully treating breast cancer. A cross-sectional study in Cape Town found that women contacted by a community health worker were more likely to return for a cervical cancer visits; the percentage of women lost to follow up was reduced from 21%-6% for 6 month visits and reduced by half for 24 month visits. Such figures signify the value of community health care workers in improving adherence to treatment.

Reconsidering diagnostic methods This practise of mass screening has been so effective that it is been strongly recommended for use in developing nations.

However the costs and lack of expertise in the majority of African countries have

made this unsuitable. Mammography is not recommend for women younger than 35 because these women have denser breasts making it more difficult to distinguish abnormal from normal tissue on X-ray film. As most African women present with the premenopausal aggressive form of breast cancer between the ages of 35-45, it is not entirely appropriate for mammography to be used in screening for breast cancer. We need to rethink the breast cancer screening strategies to suit the resource limited environment and the subtype of breast cancer presented in Africa.

In Uganda, only four mammograms exist for a population of 6-7 million and three of which are owned privately. The cost to attend an examination is $25, which is unaffordable to the average Ugandan woman.8 A study by Galukande et al. encouraged the use of ultrasounds scans and clinical breast exams for primary diagnosis of breast cancer. The cost of an ultrasound scan is less than half of a mammogram in the private sector. The study also encourages the use of sonographers, who with additional training for breast cancer, can be used in speeding up the process of diagnosis.

Ultrasounds scans may have a lower specificity and sensitivity but they are better than the alternative-nothing- even if mammography was widely available; it may not be entirely appropriate because of the subtype of breast cancer most prevalent in African women. The use of them would not lower the standard of oncological diagnosis but narrow the gap that exists.

Conclusion The burden of breast cancer in Africa is on the increase, in part due to the westernisation of lifestyle. Unless medical care and screening practices are dramatically improved, breast cancer mortality rates are projected to keep increasing. Longer prospective studies with accurate molecular biological data collection and a breast cancer registry are needed to improve our understanding of breast cancer in Africa and for the development of cost effective therapies to treat and manage the condition.

Initiatives that increase awareness and educate women in Africa on the risk of breast cancer are need to avoid delay in treatment.

Adaugo Amajuoyi Fourth Year Medical Student Further information Susan Komen for the Cure http:// ww5.komen.org/ Breast Health Global Initiative http:// www.fhcrc.org/

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Plastic Plastic Surgery, Surgery, The Brazilian woman’s woman’spower powersuit? suit? the Brazilian

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razil, the eighth largest economy in the world and a land synonymous with great football, extravagant street parties and beautiful women. Tanned, toned and flocking to the beaches in their minimal bikinis, the myth of Brazil’s women continues to lure in thousands of medical tourists each year hoping to gain a little scalpel assisted slice of the Brazilian beauty cliché. In reality, as the country with the second most unequal distribution of income in the world, it is far from a paradise littered with Victoria secret models. While one third of the population of its major cities still live in slums, and the public health system struggles to meet the basic needs of its people, beauty, natural or otherwise, still manages to retain a position of utmost importance in society. Why has beauty become so inextricably tied to the nationalist and global imagery of Brazil, and why women will go to such great lengths to attain it?

Even before the impact of cosmetic surgery Brazil was a land of beautiful people, the great racial mix created a country known for its exotic looking population, and gave beauty a high value within society. Yet the racial heterogeneity also meant that appearance became deeply linked to colour and class. In the

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early twentieth century Brazilian politicians unashamedly promoted beliefs that “whitening” the country was necessary to allow it to develop economically.

Though obviously far less extreme, the idea of whitening persists, now taking the form of hair dyes and cosmetic procedures, with Brazilian women proudly holding the title for the biggest consumers of blonde hair dye in the world.

The country’s preoccupation with appearance has propelled its cosmetic surgeons to ‘god’ like heights. Dr Ivo Pitanguy is one of the world’s most eminent and revered plastic surgeons, with both private and charity funded clinics responsible for cosmetically enhancing thousands of women each year. His Santa Casa clinic in Rio is housed in an old convent and part funded by catholic charities- a seemingly odd contradiction.

Seeing that Catholicism perpetuates the ideal women as pure and chaste, yet is financing breast augmentations and glutealplastys, whilst further reinforcing the society’s view of cosmetic surgery as an almost basic need. As Pitanguy claims of one young patient at his clinic requesting subsidized breast lift ‘to help her back pain’, ‘She is not pretty, she has low self-esteem, and she’s poor. She has no access to psychotherapy, to gyms,

to nutritional guidance. And do you think she’s going to lose weight? The reason we operate is not because of her back.

Her principal illness is Poverty.’

While it seems odd to see plastic surgery as a means to treating poverty, in a country where beauty holds such worth patients have ‘the philosophy of the masses: the beautiful live and the ugly die’1. Although rather extreme this does to an extent contain some truth, women who make up over 90% of the cosmetic surgery consumers, have much to gain from a little surgical airbrushing. Although female employment is increasing, 70% of women in the labour force still work in the services sector2 in positions such as receptionists, hotel staff and vendors. In such sectors much emphasis is placed on appearance, and a small nose or youthful face really can mean the difference between employment and poverty. This relationship between attractiveness and career success is bolstered by modern female role models such as Pamela Anderson and Jordan, women who have liberated themselves from the eighties stereotype. Gone is the prosperous business woman in her broad shouldered power suit suppressing her femininity, so she may participate in the male dominated business world and

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www.uclmedsin.org in her place are cosmetically enhanced women exploting their sexuality for greater material gain.

The Media has been quick to feed the Brazilian love of aesthetics and play on the notion that the ability to modify your appearance suggests power and wealth.

The world has been swept up in celebrity culture and accessible glamour, and Brazil is no exception. There is advertising jumping in to promise affordable procedures that will propel you into a more successful career or higher strata of society. The relatively advanced yet inexpensive healthcare infrastructure has enticed foreign doctors and cosmetic surgery tourists to the country in search of cutting-edge techniques at affordable prices. This fuels the industry, increasing the reputation of Brazilian surgeons and raising the demand among Brazilians of all economic backgrounds who feel that they are actively participating in what is almost a national project, showing the modernity of their society.

Interestingly the national preoccupation with surgery has extended to infiltrate the public health system, which offers fully subsidised procedures with none of the NHS’s reluctance. Women undergoing surgery at these clinics are aware that they are often being used to try out new techniques that can then be marketed to the paying customers but seem to be undeterred by stories of botched jobs, with waiting lists for these clinics often exceeding a year. Yet the growing accessibility of invasive cosmetic procedures is likely to lead to a loss of awareness of the very real risks that come with any major operation. There have already been 15 recorded fatalities from the popular, and relatively new technique, of the ‘Brazilian butt lift’, including the high profile death of former Miss Argentina in 2009 who died from complications following her gluteoplasty.

It strikes me that, along with the unnecessary risk these women submit themselves to, buying into the beauty market in order to gain employment may actually be widening the very gender gap these women wish to bridge. While women were made entirely equal to men in all legal terms in 1988 and the gender gap in Brazil is not vast, with a slightly higher rate of literacy and secondary school enrolment as their male counterparts; gender-related discrimination remains a primary source of social and economic inequity. While women are increasingly present in the job market, gender bias and wage inequality persist, being most pronounced in the northeast where on average women earn 63.5% of the wages of men. Men are still seen as the primary providers of the family, with the women’s wage being viewed as supplementary and women remain responsible

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for the domestic sphere, even when employed. It seems that using beauty as a doorway to employment is doing little to challenge the inequity. By using their appearance as social currency in a world where men are judged on their skills and experience women seem to be highlighting the differences between the sexes and not being judged on a par with the men they compete with.

Yet, whether we like it or not in the modern world, particularly in Brazil, appearance is closely tied to success and the very fact that the global cosmetic industry currently generates an estimated annual turnover of US$170 billion suggests that women enjoy submitting to the beauty dream. There is no denying that youth and beauty can be beneficial and there is a social pressure for women to be attractive. Ultimately, as I think the year long waiting lists for the clinics in Brazil show, women enjoy feeling attractive and this doesn’t

have to detract from other skills. The recent election of Brazil’s first female President, Dilma Rouseff, exhibits how much progress Brazil is making in gender equity. Interestingly Rouseff, who’s first presidential speech was full of the importance of gender equity, allegedly had plastic surgery herself to boost her appeal and ‘soften’ her harsh political image. Far from the extreme domineering sexuality of Jordan, yet not fuelling the feminist idea of women as victims to their beauty, Rouseff perfectly illustrates the way in which a woman can be respected for her intelligence and opinions but use her image alongside this as an added sword to her armory, making her the prefect figurehead for the many beautiful, driven women of her country.

Anna Schultze Third Year Human Science student

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Domestic Violence and HIV Neha Passi talks to Silvia Petretti from Positively UK to give Perspectives an insight into the problem of HIV associated domestic violence Silvia Petretti is a HIV positive activist with a wealth of experience campaigning for change here in the UK and across the globe. She is an HIV+ woman and activist based in London UK, one of a handful of women in the UK who are living openly with HIV. Working at Positively Women Silvia has been leading on national work, supporting HIV+ women around the UK developing self-help groups as well as providing support to drug using women

‘The pressure of being in a relationship, combined with the anxiety of being rejected because of our HIV status pushes us very often into dangerous relationships’ and women in prison. She is in the editorial team of Positively Women magazine and she contributes with regular articles, she also has her blog: The Diary of an HIV+ Activist - www.hivpolicyspeakup.wordpress.com.

Could you tell us a little bit about the work you do for Positively UK? I am a woman living with HIV and I work at Positively UK as Community Development Manager.

At Positively UK we speak to hundreds of HIV positive women every year. We meet

them in support groups, through the help-line, in hospitals and during outreach to prisons. In spite of all of our efforts we only reach several hundreds of the over 21,000 women who have been diagnosed with HIV in the UK. And reaching those women is becoming harder and harder as funding for women’s specific services shrinks.

As an activist against gender violence, how do you think HIV positive women may be particularly vulnerable to domestic violence?

From a strictly bio-medical point of view many of us are doing really well.

And I have heard so many times that HIV should be ‘normalized’ and treated like diabetes. But for most of us who are living with HIV in the UK I know that it takes more than pills to live with dignity and safety.

An area in which positive women find enormous difficulties is the area of relationships. This is a sphere of particular importance for women. Of course every human being has a basic need of feeling loved and appreciated. However, this need is amplified for women. The way gender plays in society means that women still gain a lot of status through being in a stable relationship and having children. HIV on the other hand comes with an immediate loss of value as a person in society, and this on top of other socioeconomic disadvantages women face.

The pressure of being in a relationship, combined with the anxiety of being rejected because of our HIV status pushes us very often into dangerous relationships.

2011 has started with some stark reminders of those dangers. During the Christmas holidays I was threatened with violence by an ex partner: the fact

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that I am a woman living with HIV, made me a potential ‘killer’ and of course of dubious morality. This was very much at the centre of the verbal attack and the threats of physical violence. In my expartner’s mind I obviously deserved to be treated like that because I have HIV. I was shaken, and hurt, but thanks to the support of friends and family I was able to feel a certain degree of safety. For many women for whom HIV is still a dark secret to be protected at all costs, it would be impossible to talk to anybody about such an episode and this sense of safety would be unattainable.

When I returned to work I found out that another positive woman, a close friend, had been physically assaulted and beaten. Within the first few days in January I also received a phone call from a young positive mother who is in an abusive and violent relationship, which is profoundly damaging to her and her baby.

The truth is that hardly a week goes by at Positively UK that we do not hear of a positive woman being emotionally blackmailed, abused, threatened or physically attacked.

I have used my personal example because I want to dispel the myth that violence against women is something that affects only ‘certain’ women: the ‘vulnerable’, or the ‘African Community’.

At a very personal level I have asked myself: Why has this happened to me?

Why is this happening to us as positive women? Are those men just individual ‘monsters? Who else, or what else, has a role to play in this? And I believe it is important to recognize that these are not isolated episodes but they continue to happen in the context of our societal views and attitudes towards women and HIV. What is the prevalence of cases of domestic violence in HIV positive women?

I do not have a research paper to back this up. I have 10 years of experience working for a women’s helpline and facilitating support groups.

On a global level the UK through DFID has widely acknowledged the strong link between gender inequity, gender violence and HIV. However this link has never been acknowledged in any national HIV policy strategy here within the UK. Is the abuse just physical?

No violence can manifest at many levels.

It can be psychological and emotional.

Women are often blackmailed by their partners (threatening) that if the woman

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leaves them that they will divulge her HIV status to family and friends. This is terrifying for many women. Moreover, women are often convinced that they will never find another partner who will accept them because of HIV. This creates a lot of mental stress.

Why do you think women experience domestic violence even when they did not transmit the disease to their partner and it was in fact the other way around?

It is always extremely difficult to prove direction and timing of infection. So most times it can be unclear who infected who. However, I think HIV positive women attract a lot of blame because often they get diagnosed first, during anti-natal screening, or while accessing other well women services. Because they get diagnosed first they are assumed to be the person passing on the HIV. How do support services help HIV positive women who are in an abusive relationship?

Obviously when HIV positive women face such complex and difficult circumstances it is not a surprise that our health, physically and mentally, is affected. Research shows that women have worst outcomes in regards to HIV treatment. This is due to several factors, including low numbers of women in clinical studies, and

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lack of studies focusing on women’s issues outside pregnancy. It is no wonder then that there are still only about 30 of us women who are fully open about our status here in the UK: just 30 out of about 33,000 women who have HIV here.

However, I know from the work we do that peer-lead support enables women to regain a sense of self-worth, and this has a positive effect on our mental and physical health. Being more open about HIV improves our adherence. Adherence means less resistance to treatment and no need to switch to more expensive regimes. Being successfully on ART, with an undetectable viral load, combined with openness about HIV status, also creates the foundation for preventing onward transmission. In brief, peer-led support for HIV positive women, is not just a moral imperative, it makes economic sense.

What prevents women from accessing these support services?

I think HIV related stigma still keeps women terribly isolated. Very often women don’t access a group for years, because they are so worried somebody will find out about their status. Moreover our limited funding makes it very difficult for us to increase the availability of the support we can give.

How can progress be made?

Firstly, we need some robust evidence to back our work. We need resources to develop participatory research around how gender, HIV related stigma and gender violence affect our lives as well as research on the effects of peer-led interventions.

Secondly, we need better partnership between the scientific community and HIV positive women. Scientific research, including clinical trials, should involve and support HIV positive women at every stage, from formulating questions, to collecting and analyzing data.

Thirdly, and most importantly, that support for women’s centred services and networks has to be long term and sustained, so that we, who are directly affected, can develop and maintain the strength to challenge negative societal views of HIV positive women. Stigma will end when we are visible.

Neha Passi First Year Medical Student

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Abandoning Traditional Practices: Female Genital Mutilation and its Medicalisation www.globalpulsejournal.com/blog/index

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ore than 130 million girls and women across the world have undergone female genital mutilation (FGM), the traditional cultural practice of either totally or partially removing the external female genitalia for non-medical reasons. From Senegal to Yemen, many consider FGM a part of their cultural heritage. It is not seen as an act of violence, but rather a necessary rite of passage for womanhood in order to preserve virginity for marriage.

Families who oppose it are seen as disrespecting their community, resulting in marginalisation and loss of social status.

FGM is usually performed on girls aged between 4 to 12 years by practitioners with little or no medical training. Often, crude knives and razors are used without anaesthesia, and even worse, the procedure is frequently carried out in unsanitary conditions.

FGM violates several human rights. The removal of, and thereby damage to, normal genital tissue interferes with the natural functioning of the body. The most severe form of FGM involves the removal of the external genitalia and narrowing of the vaginal orifice. The health repercussions that follow FGM are severe and lifelong, ranging from immediate haemorrhage and death, to difficulties in childbirth, and disempowering social and psychological problems.

At least 2% of perinatal deaths are attributed to complications resulting from FGM. The Medicalisation of FGM

Female Genital Mutilation/ Cutting: A statistical exploration

Growing awareness FGM and its repercussions have had a significant impact on this cultural practice. Increasingly, ‘medicalisation’ of FGM has occurred, whereby FGM is performed by health-

care professionals in order to reduce its complications. Most of these health-care professionals are part of communities in which it is the social norm, hence they carry out the procedure being aware of the reasons behind it. Other practitioners who may not themselves support the idea may still perform the operation in order to support the patient’s cultural views, or a times for monetary gain.

Some argue that medicalised FGM reduces the risk of a necessary procedure that would otherwise be carried out by a traditional practitioner .

FGM has been condemned by the World Medical Association and other professional bodies, in both its traditional and medicalised forms, including the International Federation of Gynaecology and Obstetrics (FIGO) and many governments around the world. In 2008, the interagency statement on the elimination of FGM was co-signed by 10 United Nations agencies. WHO states that medicalised FGM is not necessarily safer than traditional practices and it does not eradicate the long-term consequences of the procedure: it constitutes a breech of medical practice by breaking the Hippocratic Oath, provides a sense of legitimacy for the practice and thus does not serve as a step towards the abandonment of the procedure .

Changing Traditions

FGM/C Prevalence amongst women aged 15-19

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Although the aim of the UN General Assembly Special Session on Children (2002) to eradicate FGM completely by 2010 has not been met, significant breakthroughs have been made. Most national governments have passed laws prohibiting FGM and have developed national action plans with training of health-care

professionals. By refraining from carrying out FGM, medical professionals will contribute to the increased questioning of the benefits and practice of this common procedure. Countries like the UK, with large immigrant populations, are also becoming increasingly aware of the complications of FGM and legislation has been passed to outlaw its practice.

However, much is still to be done. In Sierra Leone, where 94% of women have been ‘cut’, the practice is still not illegal. Four female reporters were recently abducted after supporting the banning of FGM and were only released after being forced to march naked through the streets. As well as legislation, education is required to change these long held cultural beliefs. The WHO proposes that people will change their behaviour when they understand the hazards and indignity of harmful practices and when they realize that it is possible to give them up, without giving up meaningful aspects of their culture.”

In 2003, the 6th of February became the annual International Day of Zero Tolerance of FGM. Through increased awareness of FGM, together with legislation, education and community leaders speaking out against this harmful tradition, it is hoped that one day, the practice of female genital mutilation will be completely abandoned.

Lucinda Murphy Second year clinical medical student Further Reading Desert Flower, by Warie Dire. William Morrow Pub, 1998 (1st edition)

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Addressing Inequalities in Women’s Health: Who’s Job is it? http://msf.ca/blogs/ChrisH/page/2/

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mother cooks a meal for her family in the kitchen over an open flame, all the while inhaling the byproducts. She calls her family in to eat, comforted by her ability to nourish her children, yet unconcerned for her own diet.

She tidies up after dinner, finishes any necessary errands and fulfills her role as the caretaker of the home, subordinate to the head of the household.

This woman is a woman in Quintana Roo, Mexico, who is cooking tortillas from home grown farmed maize over a three stone-opened fire, unaware of the looming respiratory infection that will shape her future. This woman is a woman in Bangladesh, where roughly 52% of rural women suffer from chronic energy deficiency due to lack of proper nutrition, caused by insufficient vitamin D and iron intake. This woman is a woman in Burkina Faso, where young girls undergo Female Genital Cutting (FGC), often consider necessary for eligibility to marriage. Although these women live in different cultures, their health issues transcend borders.

Achieving gender equity in health goes far beyond the scope of any one individual nation. The United Nations has pledged to make gender inequalities and maternal health a priority in the Millennium Development Goals that they hope to achieve by the year 2015. The strategy to attack this multifaceted issue is to focus primarily on education, in the hope that fertility rates will drop and equality in other branches of society will follow. This is an absolute necessary component of both overall development and women’s health. In southern India, the state of Kerala has a low rate of post-pregnancy maternal morbidity as well as a high female life expectancy, in comparison to other Indian states that have similar rudimentary health care systems. This is unmistakably linked to many factors, including fewer gender biases in primary and secondary education, a steady incline in health care expenditure (particularly in ambulatory services for infant delivery) and the political involvement of women. Women in Kerala are motivated to effect change because they feel they have the ability to do so. It is incumbent that women empower themselves and speak for issues that concern them rather than allowing men to be the medium through which their ideas must first pass. Thus, the UN’s focus on women’s education is not only justified, but imperative to the improvement of women’s health world-

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wide.

One major obstacle lies in implementation. What is the most pragmatic approach to improving gender health disparities? In the realm of communicable diseases, poverty elimination may perhaps be the best preliminary prescription. Likewise, a push for equal education and lifestyle change is effective for non-communicable diseases. However, we increasingly exist as part of a global community this requires that we acknowledge that these types of diseases are found in different populations of women and amongst women who have vastly different cultural behaviors.

Moreover, they exist among women who universally share similar burdens. Noncommunicable diseases such as heart disease and breast cancer are often associated with high-income countries and more developed nations. In the discourse surrounding the effects of these diseases on women, initiatives usually target these populations.

However, according to recent statistics, breast cancer is “the leading cause of cancer in southeast Asian women, and is second only to gastric cancer in east Asian women, and to cervical cancer in women in south-central Asia.”(Lancet 2009) Regardless of these figures, only 5% of global spending on cancer is allocated to developing countries, where 80% of the burden of disease is found.

Fatality rates in low income countries for cancer alone is 10% more than that in high-income countries for both cer-

vical and breast cancer. Furthermore, AIDS, a communicable disease typically associated with homosexual men and Sub-Saharan Africa, is a leading cause of death of young to middle-aged African American women. Middle-aged African American women are adversely affected and they outnumber other demographics in the US for new reported cases.

By applying pressure on independent governments, we will see improvements mostly in middle to higher income countries. Currently, the research in the fields of Infectious Disease and Oncology is mostly being done in higher income countries. Although this is beneficial and necessary for any form of treatment, it will continue to be those countries that solely reap the benefits. These are global diseases that require global initiatives. This cooperation goes beyond the efforts of civil society organizations and non-governmental organizations. Lobbying governments to invest more in this sector is only the beginning and it will reach the point where it is no longer an adequate approach. Advancements in women’s health require that we address social status of women across the globe, bring their issues to the forefront and use that as a facilitator for international partnership.

Marie J Murphy International Health and Development affiliate student For more on breast cancer see Breast Cancer in Africa

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Congenital Lyphangioma Regina’s Story

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n the autumn of 2010 I had the pleasure of meeting a remarkable young lady. Her name is Regina Addae; she is 13 years old and from Ghana. She is a cheeky, lively young woman, who suffers from a congenital lymphangioma that has been growing on her face since she was 2 weeks old.

Regina’s remarkable story beings in 2004, when nurse Kirstie Randall was working for the charity Mercy Ships, at that time the hospital ship was based just off the coast of Ghana. The operation was too complicated and too risky to perform aboard the ship, but Kirstie vowed to find her the help that she needed.

Over the past 6 years, with the help of Oral and Maxillo-Facial surgeon Abi Boys, and through the charity Abi founded; Willing and Abel, £30,000 was raised for Regina. This enabled her to spend 3 months in the UK last year, where her surgery took place at Barts and The Royal London NHS Trust. She is now living happily in Ghana where her incredible story has gained her wide acclaim.

Her tumour was unlike anything the surgeon, Professor Hutchison, had seen before and - the complexity of the malformation was such that it is potentially fatal in a number of ways.

Without intervention Regina would have risked eventual death from suffocation as the aggressive tumour continued to grow into her nose and mouth eventually compressing her airway. It was also expanding back into the cranium towards the brain and ominously encircled the left internal carotid artery. This would have lead to fatal consequences had the tumour grown further into the blood

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vessel She was also extremely anaemic (Hb 6g/dl - normal levels are between 11-13g/dl for children) and loosing approximately 50ml of blood every day from her eye.

Regina’s father, Stephen, came over with her for the duration of her treatment. Since, Regina was three years old, her parents Stephen and Kate had been searching for treatment. Yet they were unable to find help, consistently being turned down due to the complexity of the surgery and the seemingly insurmountable cost. It is common, as in Regina’s case, that families are ostracised from their communities when they have a child with a deformity such as Regina’s. The locals believed that the tumour showed that Regina was possessed by the Devil, and a curse was upon her family. Traditions such as witchcraft are still deeply entrenched in the cultures of West Africa, playing a role in many areas and levels of society; it is not uncommon for people to consult witchdoctors for help with illness or advice on decisions.

Regina’s hope came from a charity founded by the Oral and Maxillo-Facial surgeon Abi Boys. Willing and Abel is a pioneering charity that exists to meet the needs of children requiring highly specialised surgery. ‘Such cases are beyond the facilities of most government and mission hospitals in developing nations, and need to be dealt with on an individual basis’ remarks Dr Boys. The charity provides connections between these children and specialist centres, assisting with visas, passports, transportation and finances. The charity ethos is that by transforming the lives of individuals; entire families, communities and nations can be transformed.

Congenital Lymphangioma - A lymphangioma is a malformation of the lymphatic system, which is the system that regulates the amount of fluid in your tissues - returning any excess to your venous system. Most are benign and result in a slow-growing, soft mass. 90% occur in children of less than 2 years of age, and involve the head and neck.

Congenital means the condition was existing at birth, or develops during the first month of life. Often the result of genetic abnormalities.

Dr Boys contacted one of her seniors, Prof. Iain Hutchison, who agreed to take on Regina’s case and undertake the procedure forfeiting his fees. The operation promised to be one with the potential for huge complications. The tumour lay extremely close to the facial nerve, a structure that controls movement to the muscles of the face, therefore playing a crucial part in facial expressions. The facial bones were already greatly distorted by the growth which wrapped around the optic nerve, making it questionable as to whether the left eye could be saved; it was already protruding three inches out of the socket.

Before the operation all those involved were concerned about a number of things: • The extent of blood loss that could occur, they had 6 units of blood ready and a perfusionist on hand to collect any blood she lost and recycle it back in.

• Whether the left eye could be saved.

• Whether the skin on the left side of her face could be saved or whether she would need, a ‘flap’, a transfer of skin from her back or arm, to her face.

• Whether she would need a tracheostomy (making an incision in the neck, into the windpipe to form a direct airway) to help her breathe.

Whilst everyone else worried over the enormity of the task, including the medical team, Regina remained confident that everything would be fine. Her confidence was founded on a dream she’d had previously where the operation had a successful outcome. A woman back in her home village of Prestea, Western Ghana, had informed Regina that she had also had a dream, in which her left eye was saved.

Regina’s faith in her dreams was rightfully placed and she triumphed against the odds. In a miraculously successful operation the one and a half pound tumour was removed in six lumps over the nine and a half hours. The perfusionist was sent home halfway through because there wasn’t even enough blood loss to cycle through the machine. The left eye was saved, all skin was conserved, and no flap or tracheostomy was needed.

This remarkable surgery shows the in-

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www.uclmedsin.org credible difference modern medicine can make to the life of an individual. Not only did this operation save Regina’s life, it gave her hope of a life that she could only previously dream of. Since traveling back to Ghana she has gone from being ostracized to enjoying new found fame.

At the airport, reporters were waiting for her and this has been followed by local television appearances. In the UK, she has made two BBC appearances and had several articles, including this one, written about her. She can now go to school, and make friends.

Regina’s success story is encouraging but can we really promote this kind of opportunity to everybody in less developed countries? Is it really economically viable to spend so much money saving the life of just one person? Why aren’t we helping the countries themselves to develop health systems so that they are able to treat their own people?

I spoke to the founder of Willing and Abel, Abi Boys, to find out more about her charities’ work and her thoughts on the ethical and social dilemmas that arise when her charity intervenes.

How do you find the Kids that come to you?

‘Well several of the kids come from a hospital in Cameroon.... I worked there for 6 months just after I graduated from Medical School. The hospital has a massive catchment area - covering Chad, Nigeria and Libya as well as covering the whole of Cameroon. So I have developed a good relationship with the people that work there and they refer cases to us.

Also the charity mercy ships refer patients to us, although Mercy Ship runs a full working hospital, in the form of a converted ferry along the coast of West Africa, they do have some limitations, and in more complex cases like Regina, they refer them to us. They needed somewhere with a big enough blood bank, and more specialist equipment for the surgery. There are also random cases that I find on my travels... such as a boy called Cedric. I met him on a plane in southern Cameroon... I could see he was jaundiced, and then he filled his nappy, I offered to help his mother as she changed him and noticed his poo was white... I suspected Biliary Atresia so took her e-mail address and things moved on from there. But we are open to receiving kids from any developing nations.

And how do you decide which Kids you can help?

Each child presents their own very complex case, and so we treat each child on a case by case basis... taking into account not only the country they are from, their condition... but also their

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family and social situation and whether it is logistically possible, it gets quite complicated sometimes. We just transferred Aboubakar from Cameroon to South Africa via Chad and Ethiopia - but if it’s possible - even if its complex we figure that child is worth investing in.

What are the main difficulties in organising for them to have treatment over here?

The difficulties range from child to child and most are from rural villages; firstly we have to get the ID cards... in order to get Passports, before we can get visas.

So you can see all the hoops we have to jump through to get things rolling. Then we often have arrange considerable transport just to get them to an airport, and brief them on very practical things such as using aeroplane toilets, using a knife and fork etc. and find suitable escorts.

What are your thoughts on the economics of so much money being spent on one person?

This is something that I am constantly thinking and being challenged about.

I think there are two ways to look at it. Firstly, if you take a look at all the problems in the world... it can be overwhelming, you can see that you can’t solve every problem therefore you have a choice... something or nothing. And I decided it’s still worth changing something over nothing. Surgery is what I love best, it’s where I can help most practically and it’s close to my heart so I decided that I will do what I can to make some difference, doing what I do best.

Secondly, with the first case we had... a boy called Abel, whom the charity is named after, I had this patient in front of me and I had to find a solution to help him. I remembered something one of my heroes said... a woman called Heidi Baker. She works with orphans in Mozambique, she says ‘Change the world by seeing the one in front of you and loving that one’ the ethos of Willing and Abel is ‘See the one Love the one’ and as a Christian I look at human beings as a creations of God. He loves each one of us unfailingly and to him we are worth everything, so I should save the life of that one child if I can... no matter what the price.

What about bringing them from their environments over to countries such as the UK for treatment?

So it’s obviously not ideal bringing them out of their own environment and we try to send them to places that are of a similar culture to their own. But, for example, with Regina there was no other option apart from the USA or UK.

We tried to find some home similarities for her here in London. A Ghanaian church was involved with her case, holding fundraising events for her here in the UK. When she was over here, Regina attended their church, where many of them spoke her language and were able to cook Ghanaian food for her and her father. We aimed to help them to not feel too overwhelmed and over exposed to our fast food, western culture, ultimately making sure that they don’t have any difficulties going back to their homeland after a sometimes lengthy stay in the western world.

After meeting Regina, I was so glad that the opportunity had been given to her in order to save her life, but I was aware of the enormity of cost and potential dangers of exposing her to apparent contradictory cultures. Although the worthiness of saving a life can never be questioned, it is important to consider if money would be better spent on long term projects and building local health systems. I think we would all agree that in the long term, building infrastructure, training locals in necessary skills and promoting health is one of the most beneficial ways to help countries ‘help themselves’ as it were, but this charity and case reveals a need, where the countries aren’t yet in a position to provide specialist treatment or help, and in this situation shouldn’t we do all that we can to fill this need? I think that the somewhat countercultural ethos behind Willing and Abel; an immense love for the individual, is an an attitude that, whilst keeping in mind the bigger picture, maybe we should be embracing more in our society today.

Jennifer Raw Second Year Medical Student

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If you don’t want to live, why would you eat?

The importance of emergency mental health care. http://cgi.wn.com/?t=worldphotos

Fizi, New Year’s Day 2011 What were you doing on New Year’s Day? In Fizi, South Kivu, in Eastern Democratic Republic of Congo(DRC), 33 women had been raped and were being attended to

by Medecins san Frontieres(MSF). Rape has long been acknowledged as a brutal weapon of war, its effects are seen more and more frequently in places such as the Burundi and Darfur. MSF, as an independent humanitarian aid organization, is best known for supplying emergency medical care, sanitation and food. However, in unusual cases like the mass rape in Fizi, the organisation can have a much broader role such as offering psychiatric help.

Background health care

to

emergency

mental

During the 1990’s in Bosnia’s killing fields MSF workers began to realise that among the camps of refugees people were dying. As far as was visible, there was food made available by organisations such as WHO and charities like Oxfam. Why then, were thousands of people literally wasting away? MSF’s mental health advisor Kaz de Jong’s answer: “Sometimes people are unable to eat because they no longer want to live.” This was a turning point for aid provision as MSF volunteers recognized that it was not enough to meet just the physical needs of people caught up in conflict. The psychological and emotional scars of war –wounds that may continue in people’s minds long after the fighting has ended– were being neglected. Between 19937 MSF implemented a comprehensive mental health programme in Bosnia that was novel in size and scope. Such was its success that in 1998 the need for mental health and psychosocial care was formally recognised.

What is involved?

Depression and anxiety can paralyse people at just the time when action is most needed. The aim of mental health and psychosocial care in emergencies is both to decrease upsetting symptoms and to increase function. The methods range from MSF trained local counsellors (where possible in line with culturally appropriate methods) to MSF psychiatrists for severe cases. Mental health care is now integrated into programmes dealing with HIV, TB, nutrition and dis-

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ease outbreaks. In the last year more than 100 000 consultations have taken place, suggesting that mental health teams really are in demand.

Obstacles Inevitably, such schemes will be subject to scrutiny and some criticism. Whilst those in favour of mental health care argue that getting to the root of the problem saves money in the long run, others point out that for supposedly ‘emergency’ care it is too expensive and time consuming. This is wholly dependent on how one defines emergency humanitarian aid. Physically, psychiatric care demands complex management often requiring a combination of drugs and counselling. The organisation of such care is further complicated by violence and ongoing trauma, meaning that a resolution is not always reached. But innovative schemes such as that being implemented in Kashmir (where MSF have been active since 2002) provide hope.

They are adapting to the violent situation by holding telephone appointments with patients, and educating about mental health through a radio soap opera “Alaw Baya Alaw” - Kashmiri for “Hello Brother, Hello”.

The future Descartes argued for a division of mind and body, in which case, bandages and HIV prophylaxis should sort out those women who’ve been raped; patch ‘em

up, they’ll be fine. But the 21st century humanitarian cannot accept this with such a backing of research and experience to demonstrate the inextricable link between mental and physical health. For the girls and women of Fizi who were bound, beaten and gang raped in front of their families, there is likely to be a powerful social stigma preventing them from seeking help and MSF acknowledges that the provision of care is limited by safety issues for the team. But at least now, 20 years post Bosnia, we realise that mental health is an emergency consideration in order to “protect the dignity of survivors and enhance the general health response”.

Women who continue to be vulnerable to the atrocity of rape will value this changing perspective.

Alice Willson Second year Clinical Medicine student and Clinical Coordinator of UCL Friends of MSF Further Reading For background on MSF Mental Health teams see ‘Focus on Mental Health’ http://www.msf.org.uk/mental_health. focus For WHO guidelines see ‘Mental Health and Psychological Support in Emergencies’ http://www.who.int/mental_ health/emergencies/en/

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70% of the two billion poor are women; two thirds of illiterate adults are women In the UK in 2008 almost 47,700 women were diagnosed with breast cancer, that’s around 130 women a day

Around 1 in 20 women (sampled in 2000) (4.9%) said they had been raped since age 16, an estimated 754,000 victims. About 1 in 10 women (9.7%) said they had experienced some form of sexual victimisation (including rape) since age 16

Cyprus has the smallest gender pay gap in the EU, whilst Malta has the largest

News in numbers

In 2008, the Gender Identity Research and Education Society (GIRES) approximated that there are only 6200 transsexual people living in Britain

women will be a victim of domestic violence in their lifetime One incident of domestic violence is reported to the police every minute 1 in 4

In Kenya there are 3 radiation machines for a population of 30 million compared with 150 machines in Canada for the same population March Issue 7

In Africa an estimated 92 million girls from 10 years of age and above have undergone FGM

Brazil is the No.1 country in the world for plastic surgery, with more than 400,000 procedures performed every year

90% of Congenital Lymphangioma occur in children of less than 2 years of age Page 19B

Perspectives

Reviews

The Immortal Life of Henrietta Lacks

by Rebecca Skoot

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was a woman? This book touches on themes central to this issue of Perspectives –gender lines, imbalance and hierarchy. But it transcends into so many other areas highlighting issues of race, ethics, and motherhood. Although, classified as a non-fiction novel, I don’t think this book can be compartmentalised. So, I will leave you with one of its many words of wisdom: “Man brought nothing into this world and he’ll carry nothing out. Sometime we care about stuff too much.

We worry when there’s nothing to worry about.”

‘There’s no way of knowing exactly how many of Henrietta’s cells are alive today. One scientist estimates that if you could pile all the HeLa cells ever grown onto a scale, they’d weigh more than 50 million metric tons—the equivalent of at least 100 Empire State Buildings.’

The Immortal Life of Henrietta Lacks has been awarded the accolade of the New York Times Best Seller thus; it is with great difficulty that I will limit myself to a few words on why this book is so phenomenal. Rebecca Skloot first learned about HeLa cells more than a decade ago, while enrolled at community college. Named after Henrietta Lacks, a poor African-American woman born in 1920, the famed cells were taken from a tumour removed during Lacks’ treatment for cervical cancer. The cancer killed Henrietta but her remarkable cells have replicated and created quite a legacy. But what did Henrietta or her impoverished family receive for her cell ‘donation’? Very little, so it would appear. Through Skloot’s emotive words readers question the hegemony of Western medicine and ethical issues in the field of genetics. As well as taking a look at the social issues- Why was Henrietta given so little acknowledgement? Annabel Sowemimo Was it because she was poor or black? Or was it because she Perspective’s Editor

Cloud Nine Inspired by Medsin’s Gender Equity campaign this fantastically vibrant play, directed by Annabel Sowemimo, (assistant director Jess Wildman) and produced by Neda Taghinejadi, did not fail to astonish audiences during its brief performance from the 10th-12th February 2011 in UCLU’s Garage Theatre Workshop.

The sexual politics in the 1970s script by Caryl Churchill were treated creatively and with unending humour: a story of two halves; it inevitably concluded with female emancipation but not without an intertwined yet inescapable story of lust, sex and complicated frivolities. This was set in two starkly contrasting backdrops with the same cast of actors: Act One in colonial Africa, and Act Two in a park in contemporary Britain.

The first half erupted with the English national anthem amongst a cacophony of Victorian English accents and outbursts. Clive, the head of the household for example announces his personal perception of the social subtleties: ‘Women are irrational, demanding, inconsistent, treacherous, lustful, and they smell different from us’. The story that proceeded told of the dynamics of a close knit family, their friends and their servants.

The marginalization of the women is forcefully exposed in their unending duties and ignored wishes; as are the hierarchical obligations of the male characters present: Clive, the father of the household imposes the way things ‘should be’ on the children. Clive’s son Edward responds melodramatically and rebels against the homophobic family traditions. Excellent performances by Richard Kennedy as Betty, Clive’s shrieking spouse and of course the booming assertive Clive himself – Dom Parker – set the tone for the crazy yet clever storyline.

and frown upon love interests that are outside of the conventional frame.

Cloud Nine is a play that is not to everyone’s liking; sat in the audience I could see the uncomfortable expressions of many peers when they realised that literally all of the characters before us were involved in a complex web of lust, frustration and emotion. The direction was innovative and daring, breaking the restrictive boundaries typically associated with British culture – whatever the characters thought -it was said, however rude and unpleasant. The concluding message was somewhat idealistic – things aren’t that simple of course – but it was refreshing to end with most of the characters’ emotional development, to realize they could be whoever they chose to be.

The second half in Britain continued exploring the themes of friendship, love, and status. Newly divorced grandmother Betty (Natalia Diaz) seeks to find her place in the world without the label of marriage; Victoria (Alice Bristow) leaves her husband for a more suitable companion Ellen-Lin (Beth Heaven and Jess Wildman); and needy partner Edward (Richard Kennedy) finds his emotional and sexual liberation without his controlling boyfriend Gerry (Thurston North); all of this not without a few glitches along the way. The overwhelming fundamental message of Act Two is to follow your heart, to ‘be yourself’ despite Cam Wratten the difficulties of modern society which attempts to categorise International Health IBSc Student

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Your Views

Each year nearly one million people across the world commit suicide, one death every 40 seconds. As a leading cause of death in the 18-35 age group, over the last 45 years suicide rates have increased by 60%. This data doesn’t include suicide attempts, which are likely to be much more frequent. Suicide is clearly a global health problem, but it is not proportional in its burden.

The WHO estimates that 85% of suicides occur in Low and Middle Income Countries. Poor data collection in these countries would suggest that these numbers are most likely under-estimated. Although traditionally there have been higher rates of suicide amongst males some countries buck this trend. India is such an example. In one area in Southern India more than twice as many women committed suicide in the 10-19 age group than men of the same age. Kerala, the most literate state in India, has the highest number of suicides with 32 people dying every day. Self immolation, or setting oneself on fire, was the third

most frequent method of suicide and is again most frequently carried out by young women. What is pushing so many young women to such extremes? Dowry disputes and conflict within the marital home is a clear driver, but with a more sinister undertone. The practice of “bride burning”, where young wives are doused in kerosene or petrol and then set alight, is still a common practice in India when dowry payments are deemed insufficient. The concern that some of these women deaths are labelled suicide instead of homicide is realistic. What is clear, is that whether suicide or homicide these staggering rates need thorough investigation. Policy and programmes should encourage young women to report domestic violence, with the judicial system protecting the victim and not the abuser.

Lauren Hookham International Health iBSc Student

Wanna hear a funny joke..?

Women’s rights.

If you laughed, please look away now…

BUT for those of you who believe that women’s rights and gender equity can be MORE than just some radical far-away notion, we are very proud to introduce MEDSIN’s newest campaign: The Gender Equity Campaign Set up in order to promote awareness of gender issues relating to health.

We believe that ALL people, in ALL countries, should have access to high quality healthcare REGARDLESS of their gender.

This does not mean that men and women should be treated EXACTLY the same; instead, we should: • APPRECIATE differences between men and women, • IDENTIFY ways in which their health statuses and outcomes differ, and • ACT accordingly.

In most societies, women have lower social status than men, leading to an international neglect of women’s health. As a result, a lot of our work will focus on women’s issues. HOWEVER, we will also be discussing inequalities that MEN experience in health. And we already even have a MAN in our group!

For more information or to get involved, please email: genderequity.ucl@googlemail.com.

We’d love to hear from you! Even if you did laugh…

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Calendar 11th March

Gender and Poverty in the 21st Century 6.00pm Location: LSE, Old Theatre, Old Building Speaker: Professor Diane Elson, Professor Nancy Folbre, Professor Maxine Molyneux

14th March

Stop transmission of Polio (STOP) and Polio eradication 12:45 pm - 2:00 pm Venue: John Snow Lecture Theatre A, Keppel Street, London WC1E 7HT Speaker(s): Yinka Kerr, STOP Program, Global Immunization Div. US Centers for Disease Control and Prevention Global mental health: the call to action Date: Monday 14 March 2011 5:15 pm Venue: John Snow Lecture Theatre, LSHTM, Keppel Street, London WC1E 7HT Speaker(s): Vikram Patel, LSHTM

15th March

Inequality and Health Conference Speakers: including Alex Voorhoeve, Adam Fletcher, James Wilson, Suzanne Wait and Jo Wolff - will examine health inequality from the perspectives of philosophy, sociology, and policy. Registration is free.

For more information and for registration, please email Erin Conrad by 5th March.

18th March

Global Health Impact: Extending Access on Drugs for Neglected Disease Professor Nicolle Hassoun, Carnegie Mellon University 1.15-2.45pm, Room 105, 24 Gordon Square, London, WC1H 0AG. To attend please email Professor Jo Wolff.

24th March

Tackling Tuberculosis on a global scale 24th March is World TB Day, which commemorates the date in 1882 when Dr Robert Koch announced the discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). Join us to explore UCL research on TB, through a series of short presentations and posters.

All welcome!

1.30-6pm, Cruciform Lecture Theatre 1 and South Cloisters, UCL. 2ND April 2001 – WALOU charity fundraiser 6-10PM at Hammersmith Town Hall, and will be based around a North African ‘souk’ theme, where we will be having stalls including jewellery, kaftans, artisans, artwork and much more!..

It will be a chance to watch the premier of a documentary commissioned by Walou, produced and edited by Horia el Hadad called ‘Morocco’s lost children’, in addition to talks by guest speakers, poetry and food.

Tickets are £20 for a limited period only and available on our website www. walou4us.com.

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Medsin UCL presents...

Perspectives

Perspectives UCL’s Global Health Magazine

We are currently recruiting: Editors Proofreaders Designers Writers Photographers No previous experience is required; all that we ask is that you have a passion for global health.

All students are welcome!

To get involved or for more information please contact: medsinmagazine@gmail.com

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

UCLU MEDSIN RUMS SOCIETY March Issue 7

Page 233

Medsin UCL presents...

Perspectives UCL’s Global Health Magazine

We are currently recruiting: Editors Proofreaders Designers Writers Photographers No previous experience is required; all that we ask is that you have a passion for global health.

All students are welcome!

To get involved or for more information please contact: medsinmagazine@gmail.com

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

UCLU MEDSIN RUMS SOCIETY

Published on behalf of UCLU Medsin by Isaac Ghinai & Martin Everson Published on behalf of UCLU Medsin RUMS by Isaac Ghinai & Martin Everson