Journal Club Recap: Violence in Bahrain Against Health Care Workers

In our first Journal Club of the school year for the Global Health Interest Group (GHIG), we discussed a recent JAMA article by M.J. Friedrich on the human rights crisis in Bahrain in which health care workers were abducted and interrogated following an anti-government protest. With the Johns Hopkins School of Medicine class of 2015 joining the GHIG discussion for the first time, there was general consensus that this incident was a clear governmental breach of medical neutrality and human rights. From this point, much of the conversation was over the role of physicians abroad, and how future physicians should view their responsibility in the global arena. A debate formed over whether physicians should report human rights violations when they see them or remain neutral and provide only medical care. An example of the latter was the Red Cross, which is able to work in several countries with restricted access because of its adherence to disaster relief  and medical care without political involvement. However, many felt that the dual role of being a physician and a global citizen motivated them to report human rights violations. A similar situation was presented from the United States in which physicians must straddle the dual role of treating a patient while being a social advocate when a situation like child abuse is observed. All in all, it was a lively discussion that began a dialogue among participants about what their own role as medical students would be in global health when faced with situations such as that in Bahrain.

Why Health Professionals Should Be Human Rights Activists

Do a Google News search for ‘health and human rights’. Do it right now.

I just did, and here were my hits:

Gays in Africa face growing persecution, activists say

Ghanaian women deserve the right to negotiate safe sex – Alliance

1,000 Ready to Take Action for Health and Human Rights in South Los Angeles Tomorrow

From the African continent to South LA, human rights violations continue to impact health in profound and immeasurable ways. And these violations range from the huge and undeniable (war, genocide, torture) to the quotidian (access to water, food, arable land, education).

December 10 was International Human Rights Day. It shouldn’t just be a day observed by human rights activists, but health professionals as well.

To anyone who argues that health and human rights are not inextricably linked, I propose the following exercise: write down the word ‘health’, then begin to list all of the words (nouns, adjectives, whatever) that can impact health. You might be stunned, as I was. This exercise transcends social determinants of health and covers vast territories of psychological, cultural, and individual factors.

WHO Linkages Between Health and Human Rights - A Beginning

I think this exercise should be required of anyone entering a health professional school. The determinants of health are so wide-ranging, involving fields with which we typically never concern ourselves (‘leave law to the lawyers, policy to the policy-makers, or human rights to the activists’). It is therefore our responsibility to educate ourselves and comprehend how fragile health is, how susceptible to millions of other currents.

As former UN Secretary General Kofi Annan said, ‘It is my aspiration that health finally will be seen not as a blessing to be wished for, but as a human right to be fought for.’

Breaking news: we are on the frontline of this war for health, and we have to fight.

Neglected diseases or neglected people?

During Saturday’s UAEM workshop on neglected diseases, one speaker brought up the point that perhaps we should not be talking about neglected diseases, but rather diseases that affect neglected people. HIV was neglected when it was thought to affect only gay men in San Francisco and it was neglected again when Africans were dying in troves even as HAART was dramatically extending lives in developed countries. Today, it remains neglected among such populations as African-Americans in Washington DC, who account for ~80% of HIV/AIDS cases in the city. And so not only do dengue, leprosy, Buruli and all the terrible “iases” remain neglected because they affect the types of people whom our society seems not to value, so do ailments that we would not intuitively place within the “neglected” category: heart disease, cancer, diabetes, which are increasing at alarming rates in the developing world. Sure, at least there is a prospect of advances in biomedical science against the diseases that affect people in developed countries, but this also means that we are restricting our efforts to interventions that are designed for the developed world and may be inappropriate/unaffordable, in other settings. There is little to no market incentive to develop interventions that specifically target the needs and constraints of poor/powerless people.

I think that the terminology of “neglected people” rather than “neglected diseases” forces us to face the underlying reason why we invest in certain diseases over others–not because they are less common or less amenable to intervention, but simply because the people who suffer from them do not have the requisite economic or political power to motivate a response. It also forces us to recognize the full scope of the neglect: it is not just disease, but also nutrition, access to education, simple interventions like ORT, civil protections… When we neglect entire classes of people, we neglect their every need, their every right, their every aspiration to “a life worth living”.

Running on hope

Just like Lakshmi (and, I am sure, many others), my summer research efforts came with a hefty dose of frustration. The lab samples I needed weren’t ready, there was no backup, everyone seemed to be on vacation, and, try as I might, I could not get across that, no, we couldn’t just put things off until tomorrow because I only had so many tomorrows left. A few days in, I was already panicking that my summer would be a waste, and nearly regretting not staying in Baltimore. With all the logistical, political and cultural issues that can make it so difficult to do global health work, why do we insist upon going halfway across the globe, not knowing whether our efforts will be worthwhile at all?

For me, the answer came, at least in part, towards the end of my stay in Morocco. My initial project was to run genotyping assays for a study of TB transmission, but as the obstacles piled up, I applied the first cardinal rule of global health: be flexible!!! I decided to devote my time instead to the logistics and patient recruitment aspects of the study and got the opportunity to meet with a group of migrants living in northern Morocco as they awaited an opportunity to cross the straits to Europe. They were the lucky ones. That very same week, 12 people had died of thirst in the desert, trying to reach northern Africa and a passage to Europe. Having lived an undeniably privileged life, one in which my daily worries and fears are pretty much limited to staying on the “P” side of Pass/Fail and taming my recurrent cravings for Chipotle, I could not imagine the depths of despair in which these men and women must be to take such tremendous risks, entrusting their lives to strangers and fate as they cross borders, deserts and seas.

The tragedy of the lives lost everyday in the deserts of North Africa and Central America, on the seas that separate Third World from First, reminds of just how important it is that we keep working towards better standards of living and human dignity for all, starting with better health. It is true that health is inextricably linked to issues of poverty, education, etc…, but it remains a critical starting point because of the powerful effects that it has on every aspect of the lives of people and societies; at its worst, disease not only debilitates the mind and the body, but also erodes the capacity for hope. When the death of relatives, friends, and colleagues become a fact of daily life, hope simply cannot be sustained, and neither can dignity. Societies in which disease and death abound will accord less value to human life loses its value, leading to the kind of social neglect, repression, and human rights violations that are the daily bread of so many in this world.

How, then, can we not justify going to the other end of the world and sparring with as many bureaucrats and corrupt officials as it takes to bring some measure of improvement? Bringing better health to every corner of the world is a daunting challenge and it may seem at times that we are fighting alone and for little reward, but it is a challenge well worth facing. For at the end of the road, lies the chance to restore not only health, but hope.

The Rohingya Report

This weekend I was talking to a good friend who works on the Hill, and she asked me if I’d heard about Physicians for Human Rights’ “Rohingya Report,” published in March 2010.  The report, Stateless and Starving, documents the atrocities committed by the Bangladeshi government against Burmese Rohingya refugees. It was written by Richard Sollom, Director of Research and Investigations for PHR and Parveen Pamar, an emergency physician at Brigham and Women’s, in collaboration with the Center for Public Health and Human Rights at Johns Hopkins Bloomberg School of Public Health.

Of course, humanitarian workers and organizations such as MSF have been on the ground in Bangladesh long before PHR released its report, but Stateless and Starving has generated steam in the U.S. and brought to light some of the shock and horror: the “dire conditions” listed in the executive summary include acute malnutrition, forced internment, arbitrary arrest, and Bangladeshi hate propaganda and violence against the refugees.