Andrew S Furber

Barriers to better care for people with AIDS in developing countries.

WHOs “3 by 5” initiative to increase access to antiretroviral drugs to people with AIDS in developing countries is highly ambitious. Some of the biggest obstacles relate to delivering care

Rebuilding health care in Iraq

Advocacy and technical support required to support professional colleagues in Iraq The effects of three wars within 25 years,1 a decade of international sanctions,2 and a brutal regime have had tragic consequences on Iraq’s health system and on the health of the Iraqi people.3 While the scale of these problems is becoming clearer, it has been difficult in the current security situation to know how best to respond to requests for help. A workshop organised by the International Committee of the Faculty of Public Health (FPH) in November 2003 has now addressed this very issue.4 This paper describes the health service needs presented at the workshop by representatives from the Department for International Development (DFID), World Health Organisation (WHO), International Non-Governmental Organisations (INGOs) and, most importantly, Iraq’s Ministry of Health. We will also consider current responses and how professional public health bodies from around the world might contribute to the development of Iraq’s health sector. The priority health service needs of Iraq where professional public health organisations could usefully contribute fall into four broad areas: communicable diseases, primary care development, health management, and public health training. These areas were identified as being of key importance by the participants at the workshop with recent experience in Iraq and concur with the assessment of the Iraqi Ministry of Health5,6 and findings of the donor meeting in Madrid.7 The potential for the outbreak of infectious diseases is clear and immediate. The cold chain for the delivery of vaccines has broken down in many parts of the country.8 Primary care facilities are often not administering the immunisation programme in an efficient manner—and even where facilities are functional staffing remains variable.9 Such disruption will also affect other communicable disease control programmes such as that for tuberculosis. …

Violence against public health workers during armed conflicts.

The recent series of fatal attacks on teachers and public health workers associated with vaccination pro grammes in Pakistan (Jan 5, p 1) have been utterly devastating. These killings have shattered the lives of the families of those who died serving their communities with basic health services. They will also undermine the eff ectiveness of vital public health inter ventions through disrupted delivery, reduced confi dence, and a demoralised workforce. Yet although these events have placed the spotlight on Pakistan, and the new form of aggressive propaganda against “west ern” public health initiatives, they are indicative of a global problem, particularly in places with armed confl icts , which requires a global response. First, we must insist on zero tolerance of violence against health workers, and multilateral agencies such as WHO should champion the cause. Although WHO has identifi ed the importance of protecting health facilities in confl ict zones, any strategy or recommendations on protecting public health workers against militant attacks is hard to fi nd. Second, donor agencies should continue to insist on reasonable protection for health workers, including programmes to prevent violence. Commissioners and managers of health services should be required to include the protection of health workers in their responsibility for delivering public health services. Health workers, by their very nature, will often want to take risks to provide services to the poor. Although we have no wish to stifl e this altruistic spirit, to expose health workers to risks that could be mitigated could be seen as criminal, or at least immoral. Third, further research is needed into eff ective actions to prevent violence against health workers, especially in resource-poor settings. In the otherwise excellent World report on violence and health, health workers are seen as part of the response to violence and their own need to be protected is not adequately addressed. Fourth, health workers and health programmes should never be used as cover for military action. There should not be any blurring of the boundaries between the humanitarian activities and military campaigns in confl ict zones. Such actions provide an easy excuse for those who wish to perpetrate violence against civilians and potentially undermine community confi dence in health services. It could cost more lives in the long run. Fifth, there should be a comprehensive communication and health promotion strategy, developed in collaboration with religious and other community leaders, to counteract any anti-vaccination propaganda by extremists. Finally, specifi c humanitarian action is required to ensure that basic health services continue to be provided in Afghanistan and Pakistan. Along with Nigeria, these are now the only three countries in the world where polio remains endemic. The failure to eradicate polio is symptomatic of the diffi culty of providing basic health care. We must ensure that the deaths of these courageous health workers were not in vain, and that essential health care is delivered to the poor in Pakistan.

The need for a new Tobacco Control Plan: an issue of justice

The prime minister’s commitment to “fighting against the burning injustice that if you’re born poor, you will die on average nine years earlier than others”1 is welcome and achievable. As her government has acknowledged,2 half of this difference in life expectancy is due to the higher rates of smoking among the least affluent, so major improvements can …