International Health

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International Health

• Whats Happening on the Field

Nikhil Pai, Amane Abdul-Razzak, Hinal Sheth,
Sarah Hynek, Baldeep Chera, Megan Arthur, Saira
Nawaz, Jessica Liauw, Katy Smali
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Goals of Todays Presentation

• Offer you a whirlwind look at whats happening in
  International Health today
• Whos involved
• Access to Essential Medicines Campaign
• Engineering Public Health The West Bank Iraq
  Case Examples
• Whats happening at McMaster University
• Questions for discussion
• Please write on cue cards during presentation

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Organizations Operating Today

• Overseas medical aid isnt a new concept
• Numerous stories of World War army medics
  treating the enemy
• 1929 Geneva Convention duty exists to respect
  the sick and wounded, regardless of nationality
• Today, over 195 organizations exist that need
  medical personnel for their humanitarian
  operations
• Oxfam
• International Rescue Committee
• Originally set up at the request of Albert
  Einstein to assist opponents of the Nazi regime
  fleeing persecution
• Operation Smile (reconstructive surgery)
• United Nations Volunteer Corps
• World Vision
• UNICEF

• MSF
• Red Cross

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Red Cross and MSF
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Red Cross and MSF

• Inside besieged Biafra (contd)
• Attacks on Biafran hospital workers by the
  Nigerian Army
• Civilians murdered
• Thousands of children starved by the blockade
• Red Cross required volunteers to sign agreement
  to uphold the organizations neutrality
• French doctors saw this as a gag order
• Publicly criticized Nigerian government and Red
  Cross for its complicit behaviour
• In 1971 Médecins Sans Frontières was born
• we will ignore political/religious boundaries
  and prioritise the welfare of victims
• Today, MSF fosters the concept of témoignage
  (witness)
• acting and speaking out are not two inseparable
  elements of relief
• MSF will firmly speak out when it sees that those
  it is trying to help are being abused by
  violations of international humanitarian law and
  medical ethics.

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Safety of Internl Health Workers

• Stray bullets, landmines, epidemic diseases
  always a concern
• Kidnappings and politically motivated attacks on
  the rise
• In the past, this was mediated by aid
  organizations being perceived as exclusively
  helping the enemy
• War on Terror has generated attitudes in
  US-occupied countries that NGOs are allied with
  Coalition forces
• US labelling its operations as humanitarian
  actions
• Military planes dropping care packages M/W/F
  and bombs T/Th/F

July, 2004 MSF in Afghanistan evacuated after 5
volunteers were killed in an ambush May, 2005
MSF volunteer arrested in Sudan for reports on
the rapes by pro-government Janjaweed militias
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• Emblems that once were proudly emblazoned on
  vehicles and base-camp flags as protection, are
  now seen as targets

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Access To Essential Medicines

• One-third of the worlds population lacks access
  to essential medicines in the poorest parts of
  Africa and Asia this figure rises to one-half.
• Why?
• Many existing/new drugs too expensive.
• Increasing resistance to older medicines.
• Discontinued production of effective medicines.
• Very few new drugs developed to tackle major
  diseases of poorest countries.

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Access To Essential Medicines

• Market Prospects vs. Health Needs

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Access To Essential Medicines

• Drug Development Outcome

1975-1999 1393 new chemical entities marketed
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Access To Essential Medicines

• International Campaign Started in 1999
• 3 main objectives
• Stimulating research and development for drugs
  and neglected diseases.
• Overcoming barriers to existing medicines
  (patents and prices).
• Lobbying to overcome trade barriers.

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Access To Essential Medicines

• Campaign Strategies
• To lower drug prices on a sustainable basis
• Encouraging generic competition
• Local production
• Increased research into neglected diseases
• Investing in RD in developing countries
• Bring back production of unprofitable but
  medically necessary drugs

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Access To Essential Medicines

• Campaign Achievements
• 1) Access to medicines now an international
  concern.
• 2) Price of AIDS drugs fallen dramatically,
  leading to international push to treat HIV in
  LDCs
• - 1999 US 10,000 per patient/year
• - 2001 300 per patient/year
• 3) Critical analysis of institutional policies
  and practices WHO, WTO. GFATM, UN
• 4) Established the Drugs for Neglected Disease
  Initiative a new model for drug development
  (www.dndi.org).

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The Importance of Accessibility The West Bank
Example

BBC News bbc.co.uk
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Background on the Wall

• Construction began in June 2002
• Will span 622 km when completed1
• System of 8-metre concrete slabs, fences, barbed
  wire, regularly groomed trace sand, patrol roads,
  electronic monitoring
• Cost 4.7million/kilometre (USD)2
• Tangible representation of the multitude
• of barriers that Palestinians have faced
• in the occupied territories

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Impact of the Wall on Access to Essential Health
Care

• The wall has regularly disrupted access to
  hospitals, private doctors, specialists,
  laboratory services and other forms of health
  care for roughly 200,000 Palestinians3, according
  to 2002 statistics
• As the project nears completion, an estimated
  32.7 of all West Bank Villages will be denied
  free access to health care4
• Residents of the West Bank need a medical permit
  in order to receive treatment from hospitals in
  Jerusalem
• Long, arduous procedure
• Valid for only a limited period of time
• Provides no guaranteeaccess to Jerusalem is
  dependent on the judgment of soldiers at
  checkpoints, who lack medical knowledge

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Impact of the Wall on Access to Essential Health
Care

• Average transport time by ambulance from the
  Aizaria and Abu Dis area to Jerusalem has
  increased to 1 hour and 52 minutes (versus 5-10
  minutes prior to the wall)1
• Long-term outcomes for some common medical
  situations (e.g., stroke, heart attack, allergic
  reaction, asthma crisis) are largely dependent on
  time to treatment
• Significant impact on trauma cases
• Health Care workers regularly face access
  difficulties
• Ambulances prevented from traveling to Jerusalem,
  despite Israeli civilian administration orders
  (decision rests in soldiers hands)
• Doctors denied access to their clinics case
  reports of doctors being forced to do physical
  exams and administer treatments across fences

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Other Impacts

• Lack of access to
• Laboratory tests, diagnostic tests
• Specialists
• Other forms of tertiary care (e.g., dialysis,
  cancer treatment)
• Drinking water 50 wells have already been
  annexed1 difficulties in accessing clean
  drinking water will worsen as the wall is
  completed
• Mass majority of men living near the wall
  depended on Israel for their income
• Now cut off from employment sourcesaffects
  patients ability to pay for treatments and
  medicines
• Patients often forced to choose amongst their
  prescriptions or to purchase only a portion of
  the pills

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Aid for Palestine

• MSF (since 1988)
• Medecins du Monde
• Canadian International Development Agency (CIDA)
• International Committee of Red Cross (ICRC)
• Palestinian Red Cross Society (PRCS)
• Palestine Childrens Welfare Fund
• Limitations/Obstacles to aid are significant and
  include checkpoints, limited access across
  borders.

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Importance of Infrastructure The Iraqi Example

• Complex issues in Iraqwill focus on a single
  dimension
• Since the Gulf War in 1991, there is a dramatic
  regression in overall infrastructure
• Communications systems
• Roads
• Power supply
• Schools
• Water Supply
• Sewage
• Etc

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The Transition

• Previously (1990), standard of health care on par
  with western Europe
• Health budget cut by 90 during sanctions
  reduced life expectancy, surge in malnutrition,
  dramatic reduction in available medical
  treatments, infectious disease epidemics
• Today, basic needs remain unmet
• wartime damage to water treatment facilities gone
  largely unrepaired6
• 46 of households lack access to drinking water5
• food availability still sparse for many

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The Problems

• Instability
• Lack of Experience in Public Health
• Conflicting priorities
• money used for building renovation projects
  (ministry of health headquarters, hospitals),
  meanwhile
• little/limited fund allocation for more pressing
  public health issues (e.g., sewage treatment,
  public health messages, immunisation programmes)
• Corruption stealing and black market sales of
  medicines
• Assignment of US Defense department for
  post-occupation humanitarian efforts
• Assumption that there would be no infrastructure
  loss, no humanitarian crisis
• The list goes on

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Whats Missing

• Better training for health care workers (training
  given by NGOs is too basic for needs of health
  care staff)
• Better sanitation, water supply
• Public health training (to allow for more
  effective resource allocation)
• Mental health (e.g., to tackle post-traumatic
  stress disorder)
• More insight into the way Iraq society operates
  (cultural sensitivity, norms, etc.)

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Aid In Iraq

• International Federation of Red Cross (IFRC)
• UN Assistance Mission for Iraq (UNAMI)
• UNICEF
• War Child Canada
• Canadian International Development Agency (CIDA)
  (via monetary donations to other NGOs)
• CARE (out in late 2004 after abduction of
  director)
• Medecins Sans Frontier (out in December 2005)
• Medecins du Monde (out in April 2004)
• Hostile Environment for NGOs

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Peace Through Health

• Health initiatives can bring about peace in the
  form of social healing in war zones, humanitarian
  ceasefire and health expertise to restrict
  weapons and war strategies
• Use of Health Related Superordinate Goals
• Healing of trauma
• Contribution to civic identity
• Contribution to human security
• Redefinition of the situation

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Peace Through Health

• Peace Through Health in Action
• Butterfly Peace Garden, Sri Lanka
• -use of play and art therapy to remedy mental
  trauma due to ongoing ethnic conflict
• Landmine Awareness
• -Mine Ban Treaty ?Ottawa, Canada December
  1997
• Afghanistan Peace Education Program
• -2000-2001

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On the Home Front

• What are we doing at McMaster?
• SIHI
• Workshops
• Medical Outreach
• Peace Through Health
• Aboriginal Health Conference
• Overseas

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Infrastructure in Developing Worlds
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Infrastructure in Developing Worlds

• Infrastructure plays an important role in a
  countrys development as it includes roads,
  electricity, water and sanitation, etc.
• Many sub-Saharan African governments spend less
  than 20 per patient per year on all health care.
  As a consequence, public health systems in
  developing countries are unable to deliver health
  care products and services to the people who need
  them. As a result of this the health care
  conditions are extremely poor in much of the
  developing world.
• (Health Care in the Developing World).
• Without proper roads people and medical supplies
  are unable to reach medical facilities.
• Without electricity vaccines are not refrigerated
  and the general functioning of the facility is
  extremely limited.
• A lack of clean water leads to the spread of
  disease. In Tanzania, only 49 percent of the
  population has access to safe water. Sanitation
  facilities are available to only 23 percent of
  the population in Mozambique and to 16 percent of
  citizens in India (Health Care in the Developing
  World).

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Infrastructure in Canada

• Reasoning Student International Health
  Initiative (SIHI) and the McMaster First Nations
  Student Association (MFNSA).
• A group of students interested in raising
  awareness of issues pertaining to social justice,
  specifically when it comes to health and First
  Nations issues.
• struggle for good health through two separate
  events, the Aboriginal Youth Health Symposium and
  the Aboriginal Health Conference.

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Infrastructure in Canada

• Canadas Performance in 2005 Aboriginal Peoples

1. Health improved health of Aboriginal
peoples 2. Lifelong learning maximized
participation and success in early learning,
education, training, and skills development built
on Aboriginal heritage 3. Safe and sustainable
communities Aboriginal communities are safe,
stable, and sustainable 4. Housing Aboriginal
people have improved access to suitable,
adequate, affordable housing and related
support 5. Economic opportunities sustainable
wealth creation and participation in the economy
6. Lands and resources sustainable use and
management of First Nations and Inuit lands and
resources by First Nations people and the Inuit
7. Governance and relationships sound
Aboriginal governance and support of
institutional capacity and clarification of the
respective roles in the relationship
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On the Home Front

• McMaster School of Medicine
• McMaster Medicine Faculty
• Samantha Nutt Eric Hoskins (War Child Canada),
  James Orbinski (MSF), Lynda Redwood-Campbell,
  Saleem Yousef, Ally Prebtani, Joanna
  Santa-Barbara, Brian Cameron

• Student International Health Group

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On the Home Front

• McMaster School of Medicine (contd)
• Students
• International Elective Opportunities for
  Undergraduate Medical Students, and Medical
  Residents
• AFRICA (Uganda, Ghanda, South Africa, Zimbabwe,
  Kenya, Angola) ASIA (Malaysia, Nepal, India,
  Israel, Hong Kong) EUROPE (Ireland, England,
  Finland, Scotland) SOUTH AMERICA (Dominican
  Republic, Cuba)

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On the Home Front

• One students international elective experience
• Worked 1 month in small district hospital in
  Livingstone, Zambia 1 month in national public
  hospital in Nairobi, Kenya
• Came away with so many new perspectives
• An exceptionally motivating experience for a
  young idealistic student
• A disturbing reminder of why so much of this work
  is mired in a sentiment of hopelessness

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On the Home Front

• Personal reflections
• The uphill struggle to prevent apathy in patient
  care in the developing world
• Market-oriented economics of the pharmaceutical
  industry defining priorities over genuine health
  needs
• Lack of provision of mental health services
• The frightening callousness of publicly funded
  health care in a two-tier health care system
• Glimmers of inspiration in a place of
  frustration, lawlessness, and corruption

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A Fair Share of Controversy

• Discussion
• What is the goal of International Health?
• Are we just offering band-aid solutions that
  dont change anything in the end?
• Is enough being done for prevention, and health
  promotion?
• Is there any economic worth to saving human lives
  (and how do we convince governments to believe
  there is any?)
• How do we convince pharmaceuticals to make their
  medications more universally available?
• Are drug trials in developing countries ethical?
• Nevirapine drug trials in Africa

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References

• Medecins du Monde The Ultimate Barrier
• Israeli Ministry of Defense at
  www.seamzone.mod.gov.ll/Pages/ENG/questions.htm
• HDIP, 2002
• Btselem
• Labonte, Ronald. Iraq doctor tells of health
  crimes. BMJ 2005331252.
• Dyer, Owen. Infectious disease increase in Iraq
  as public health service deteriorates. BMJ 2004
  329940
• Medecins sans Frontieres http//www.msf.org/
• Access to Essential Medicines http//www.accessme
  d-msf.org/

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• There are limits to humanitarianism. No doctor
  can stop a genocide.
• No humanitarian can stop ethnic cleansing, just
  as no humanitarian can make
• war. And no humanitarian can make peace. These
  are political responsibilities, not humanitarian
  imperatives. Simply put, the humanitarian act is
  the most apolitical of all acts, but if actions
  and its morality are taken seriously, it has the
  most profound of political implications. And the
  fight against impunity is one of these
  implications.
• Despite grand debates on world order, the act
• of humanitarianism comes down to one thing
  individual human beings reaching out to their
  counterparts who find themselves in the most
  difficult circumstances. One bandage at a time,
  one suture at a time, one vaccination at a time.
  All this in the hope that the cycles of violence
  and destruction will not continue endlessly.
• Dr. James Orbinski, December 10, 1999
• excerpt from Nobel Prize Acceptance Speech