Rhona MacDonald

Providing clean water: lessons from Bangladesh.

The people of Bangladesh are being slowly poisoned. Although the world has known this since 1998, the full implications are only just being realised. Up to 57 million of Bangladeshs 130 million inhabitants are drinking water that contains harmful concentrations of arsenic.1 The tragedy is twofold: it was a well intentioned public health measure that caused the problem in the first place, and there are no easy solutions. Discussion at a meeting in January between the Department for International Development, the British Geological Survey, and non-governmental organisations emphasised the difficulties of reaching a workable long term solution. The World Health Organizations provisional guideline is that drinking water should contain no more than 10 μg/l of arsenic,2 though the Bangladesh standard is 50 μg/l. Water samples from many Bangladeshi tubewells have concentrations exceeding these values, with extreme concentrations greater than 500 μg/l. 1 3 Chronic arsenic ingestion has many health consequences, ranging from skin disorders to cancer, diabetes, and cardiovascular, respiratory, and peripheral vascular …

Equality for people with disabilities in medicine

Time for action and partnerships As a result of our advances in medical science and technology more lives are being saved than ever before, although many people who are saved from death are left disabled. Add to this the expansion of the ageing population, in whom the prevalence of physical impairments is highest, and disability emerges as a major facet of modern society–one in four people in the United Kingdom has a disability or is closely associated with someone who has.1 Disability has become part and parcel of our human experience. By definition, therefore, the challenges facing citizens with disabilities are now a major “mainstream issue,” both for society in general and for the medical profession in particular. Yet several reports and studies indicate that doctors commonly fail to identify and tackle disability issues.2–6 Why is it that health professionals often seem unwilling or unable to engage with people with disabilities? One reason may be the poor record that the medical profession in the United Kingdom has in treating people with disabilities as equal within its own ranks. We recently organised a two day conference to …

Recruitment of doctors to non-standard grades in the NHS: analysis of job advertisements and survey of advertisers

Objectives To estimate the proportion of advertised non-consultant hospital posts that do not conform to nationally recognised terms and conditions of service and to investigate why these posts exist, who fills them, and what the doctors in such jobs do. Design Analysis of job advertisements and a cross sectional survey of advertisers. Setting Job advertisements in one of the leading UK publications listing hospital doctor vacancies (BMJ Careers). Results Nearly a quarter of non-consultant posts advertised in the two study periods (23% and 21%) were for non-standard grade posts. A questionnaire was sent to the medical staffing officer for each post. Of 430 questionnaires sent out 192 (45%) were returned. 98 trusts said they advertised non-standard grades because there was no more funding from the deanery for approved posts and 75 because service needs could not be met by doctors in training grades. In 132 posts (69%) the post holder would be required to do on-call work, and 50 advertisers (26%) required on-call duty for 1 in 5 or more frequently, which would conflict with the European Working Time Directive. 131 advertisers (68%) expected the posts to be filled by doctors from outside the European Economic Area. Conclusions Non-standard grade posts are mostly being created to meet service requirements when there is no more funding for standard training posts and are expected to be filled by doctors from overseas. Doctors in such posts can be more easily exploited and their careers hindered. The Department of Healths annual census should include non-standard grade doctors.

Career advice for doctors with a chronic illness

Career Focus bmj.com/content/vol322/issue7295/#CAREER I have scleroderma. Eighteen months ago I was advised by an occupational health physician to retire from the NHS on grounds of ill health. I was 30. Determined not to let my medical skills go to waste, I was left on my own to find a niche for myself which matched my health needs and allowed me to carry on working. My situation is not unique, and in this weeks Career Focus ( BMJ Classified p 2) some doctors who have chronic illnesses summarise their experiences and give advice to other doctors who may find themselves in a similar position. This week also sees the launch of Career Focuss mentoring scheme for doctors with chronic illness. Doctors who have a chronic illness have a rough deal. As well as having to come to terms with their illness, they also face problems in their career. Inflexible working patterns, poor contingency cover, …

Bringing disability off the sidelines: a call for papers

www.thelancet.com Vol 373 March 28, 2009 1065 anaemia and vitamin-A defi ciency remain severe public-health problems. In Lebanon, the prevalence of anaemia in Palestinian refugee children younger than 3 years in 2004 was 33·4%, which makes it the highest in Palestinian refugees who live outside the occupied Palestinian territory (28·4% in Jordan and 17·2% in Syria). In the same survey, the prevalence of anaemia in the West Bank and Gaza Strip was higher (34·2% and 54·7%, respectively). Mental disorders, related to the chronically harsh living conditions and longterm political instability, violence, and uncertainty are becoming a public-health concern. In Lebanon, 19·5% of Palestinian refugee adolescents suff er from mental distress, and 30·4% of women in the same refugee camps reported mental distress. The data depict a complex situation, with emerging diseases and chronic and endemic unsolved health problems. Although UNRWA has eff ectively assisted refugees so far, their increasing economic vulnerability makes them increasingly dependent. The future of Palestinian refugees will be conditioned by how children are followed up in their development and growth, how women are protected from negative outcomes of pregnancy, and how the adult population is treated and counselled for leading diseases. By providing the best possible primary-health-care services, UNRWA is enabling these refugees to hold their destiny in their own hands. We have summarised the health status of Palestinian refugees who live outside the occupied Palestinian territory. These refugees do need remembering as well, in addition to those populations described in The Lancet Series on health in the occupied Palestinian territory.

Who can lead the world on human rights

Last month, the non-governmental organisation (NGO) Human Rights Watch released its World Report, 2007— an annual review of human rights practices from around the globe. The catalogue of atrocities detailed in the comprehensive 500-plus-page report, highlights how the world desperately needs a champion to defend, support, and promote human rights practices. In addition to the worsening humanitarian situations in Darfur and Iraq, the report details the many other human rights challenges in need of urgent attention: the ruthlessly oppressive regimes of Turkmenistan and North Korea, Russia’s crack down on NGOs, the civil war in Sri Lanka, and Robert Mugabe’s preference to ruin Zimbabwe rather than face political opposition. The organisation highlights widespread practices that need to be tackled, such as the use of torture by regimes and police forces around the world. One of the report’s main conclusions is that the USA cannot provide credible leadership on human rights. “Washington’s powerful voice no longer resonates after the US government’s use of detention without trial and interrogation by torture”, writes Kenneth Roth, executive director of Human Rights Watch. The organisation is not alone in their view. Leonard Rubenstein, the executive director of Physicians for Human Rights, told The Lancet: “The USA has gone beyond abdication of leadership on human rights, as its use of torture and secret detention, and its denial of asylum for those fl eeing persecution have encouraged human rights abusers worldwide.” As for other countries, Roth believes that China remains indiff erent to human rights practices of others and ignores the issue of its own practices altogether: “Beijing pretends that human rights are an internal aff air when dealing with others abroad.” And he thinks Russia is going down the same path: “Its goal seems to be rebuilding a sphere of infl uence... even if it means embracing tyrants and murderers.” Roth concedes that emerging southern countries in Africa and Asia off er rare glimmers of hope before turning his attention on the European Union (EU), which he says is punching well below its weight on human rights issues. He cites many reasons for why the EU is falling woefully short of its promises as a defender of rights around the world. For example, the way that the EU operates in its decision making, especially at the UN Human Rights Council, in which the insistence of a consensus agreement causes delays in decision making, refl ect the EU’s preference for unity over eff ectiveness. The rotating presidency is also an issue. According to Roth, “It is diffi cult to imagine a less eff ective way to maintain continuity or build expertise than the EU’s rotating blur of six-month leaders”. But much of the problem is due to a simple lack of political will: “Promoting human rights can be costly and diffi cult, and many governments do not want to bother–at least beyond lip service”, writes Roth. Peter Hall, director of Doctors for Human Rights believes that it is not only governments who should shoulder the responsibility of human rights. He says: “Citizens must be educated in human rights so that electorates can infl uence domestic and foreign policy in democratic counties.” But the world may already have a human rights champion in Norway. The country has taken the lead in helping the world to achieve the fourth Millennium Development Goal (MDG4), which aims to reduce by twothirds the mortality rate in children aged under 5 years. Jens Stoltenberg, Prime Minister of Norway, thinks that Norway’s work on MDG-4 is also helping to promote human rights. “I cannot think of any other endeavour that so eff ectively promotes human rights and fundamental freedoms than giving opportunities for healthy childhoods, safe motherhoods so that families can raise their children with greater hope for the future”, he told The Lancet.

Transferring patients with Ebola from west Africa to "isolation hospitals" in well resourced countries for treatment.

The latest predictions regarding the spread of Ebola in west Africa are alarming and leave little time for effective action.1 2 A possible solution would be to transfer Ebola positive patients to suitable “isolation hospitals” in well resourced countries. Our recent experience in Liberia suggests there is too little time to create and staff enough Ebola treatment units (ETUs) to control the epidemic.3 In west Africa, increasing numbers of …

Violent conflict and health: a call for papers

www.thelancet.com Vol 373 May 23, 2009 1747 Second, skill in imparting information that is cognitively and emotionally compelling and easy to use requires both new forms of training for medical professionals and the use of team members with these particular skills. Techniques developed for treatment of other conditions can be applied to diabetes education and medical care. These techniques include motivational and cognitive behavioural methods designed to address patients’ beliefs that impede self care. Third, augmenting the traditional skills of medical diagnosis and treatment with adept assessment of behavioural, psychological, familial, and social issues important to the patient is a much needed basis for lessening barriers to improving self-care. This approach includes identifi cation and treatment of common psychiatric syndromes, such as depression, which occur at higher rates in patients with diabetes and which infl uence outcomes of care for diabetes and other medical conditions. Importantly, whilst these therapies are eff ective for treating psychological problems in patients with diabetes, how best to implement them in clinical practice to benefi cially aff ect the course of the disease is not yet clear. Fourth, shared ownership is a challenge because patients live with their disease full time, whereas we see patients a few hours a year. Groups can extend the sense of caring and support through others who are facing the same problems. This sense of connection can be further extended with advancements in technology. Online chat rooms began a trend carried forward today by increasingly sophisticated and engaging methods of connection, which might help to decrease isolation and provide new sources of information and hope. Creation of the “medical home”, linking the patient to a network of caregivers via electronic personal medical records could help increase support. However, further research is needed to evaluate the eff ectiveness of such approaches. Development and careful testing of psychological techniques and their translation through randomised trials are urgently needed to bring advances from the educational and behavioural laboratory into clinical practice. Moreover, the value of developing such techniques will be limited and advances in clinical outcomes and patients’ well-being impeded if we cannot partner with funders of health care to radically restructure methods of payment for treatment of chronic conditions such as diabetes.

The continuing battle over baby-milk formula

A recent briefing paper by the charity Save the Children UK and an investigation by the Guardian newspaper highlight that inappropriate activities surrounding baby-milk formula marketing and promotion cannot be resigned to the pages of history. 25 years on from the introduction of the WHO International Code of Marketing Breast Milk Substitutes food companies persist in their dubious practices but in a more subtle manner than in their aggressive activities of 30 years ago. Most importantly such practices are still responsible for the deaths of thousands of children. In 1970s an international campaign against the food giant Nestle was responsible for eliciting such collective outrage that it led to one of the biggest public boycotts in corporate history. Subsequent international pressure resulted in the WHO code which not only covers the marketing of infant formula but also other commodities if promoted as partial or total breastmilk replacements. (excerpt)

Gunilla Backman: putting the right to health into practice

Not many people are fl uent in fi ve languages and have worked in places like Kosovo, El Salvador, East Timor, Nauru, and Guatemala, but Swedish-born health and human rights expert Gunilla Backman is one such person. As one of the project leaders of the right to health for health systems report, Backman’s passion for human rights and a desire to help communities in a practical way has led to an unconventional career. Backman’s desire to help vulnerable people fi rst came to light while she was living in southern Spain as a child and saw the plight of the gypsy community there. Later, after a degree in international aff airs at the American University of Paris, France, she started as an intern at UNAIDS on the very fi rst day of the organisation’s creation. Here she learnt a valuable lesson from her mentor, Susan Timberlake, senior adviser in human rights, law, and gender policy. Backman recalls: “She told me that the best way to understand health and human rights was not by sitting in Geneva, but by working with the people in the fi eld.” Backman spent the next 7 years doing intense fi eld work. She headed to Bosnia fi rst, just after the end of the Balkan war, to set up a community centre for Serbs, Croats, and Bosnians. But events unexpectedly led her to work for WHO: “I was on my way to Belgrade by bus to do some consultancy work for UNAIDS. As I was on a bus, I got through OK but the WHO convoy was stopped at the border and not allowed through so they relied on me to do some work for them.” Backman became WHO’s Vulnerable Groups Programme Manager in Bosnia Herzegovina for 2 years. It was at this time that she saw the right to health in action for the fi rst time. “We asked the local NGOs from three enclaves what they wanted to focus on and they all said, ‘domestic violence’. So WHO funded a workshop, attended by NGOs from all three enclaves, UN agencies, and ministries. We took a participatory approach—one of the fundamental foundations of the right to health—where the NGOs all had their say in the resulting strategy.” This was also the time, 1997, when Kofi Annan stated that human rights should be streamlined throughout all the UN agencies—something that is still a distant dream today. According to Backman, there is nothing really new about the right to health approach—that is, taking a participatory and systematic approach to deliver a plan that can be monitored by benchmarks and indicators. To help develop this approach Backman took the advice of another mentor at this time, Renzo Bonn: “He told me that if you really want to engage with the people, you should speak the language and you need to listen. Otherwise, how can you have a truly participatory approach?” Backman became fl uent in some of the languages of the countries where she has worked. Although Backman had worked in the health fi eld for many years, she had no formal training in health. She, therefore, came to the UK in 2003 to complete an MSc in Health Service Management at the London School of Hygiene and Tropical Medicine (LSHTM) followed by an MA in Human Rights at the University of Essex. She recalls, “The lawyers were brilliant but they had little understanding of health in practice.” And equally, at the LSHTM, she thinks that the teaching on health was “fantastic” but there was little practical knowledge of human rights. A desire to put her knowledge into practice led Backman to the fi eld again as fi eld co-ordinator for Médecins Sans Frontières in Guatemala. The hand-over of an HIV/AIDS clinic to the Ministry of Health excited her. “This was the right to health approach in action.” 3000 people with HIV used the clinic and their representatives and hospital staff took part in planning the hand-over. “This way, everyone had to take responsibility and what was, and what was not done, became transparent”, she says. The impact of the application of the human rights approach was also evaluated 2 years later. Backman used this experience to inform her work as a researcher in health systems for Paul Hunt, who was then the UN Special Rapporteur on the Right to Health, and had been her supervisor at the University of Essex. She helped to drive forward the right to health for health systems report, published in The Lancet this week. She also developed, and with Hunt implemented, an innovative course, “Theory and practice of health and human rights”, for postgraduate law students. Students are taught by health experts and lawyers and explore how human rights theory can be put into practice. Its success means that Backman will run a similar course at Sweden’s Nordic School of Public Health in 2009. Now working as a consultant for the GAVI Alliance, Backman refl ects on her time spent with Hunt. “Paul is so open-minded and he strives to make all of the theory operational.” Backman also shares this goal. She thinks that the human rights community and health sector have much to learn from each other in terms of developing systematic approaches and using research and evaluation. If the right to health shall be made real, at a minimum the two sectors need to work together and be willing to learn from one another. As Backman asserts: “If the results of research are not put into practice, what is the point of doing the research? Research should be more than ticking the right box. It must lead to improving people’s health and lives. The positive fi ndings need to be put into practice.”