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.

Yeah, the CIA doctors violated the Geneva Conventions…

…but what about the Nuremberg Code? Or human research protocols? Or that most intangible of standards, the Hippocratic Oath?

It was Greek, originally

As a refresher, the original HO, reproduced below:

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art – if they desire to learn it – without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

One could argue many points in the traditional Hippocratic oath, particularly the “I will not give to a woman an abortive remedy” bit.  So much so, that the modern version dispenses with some of its tenets entirely. The underlined ones above, however, seem pretty universal. And while it would take a superhuman doctor to fulfill all of these ideals, it should be our aim as physicians at least to strive for them.

The behavior of the CIA doctors, who not only monitored interrogations and helped conduct waterboarding sessions, but also gathered data (as yet unconfirmed by the CIA) to “improve” said interrogations, has come under scrutiny from a variety of media and human rights organizations. Most egregious is the fact that their function was to serve “no therapeutic purpose”.

In the past few months/weeks/days, their actions have been widely decried on international and historical grounds. Comparisons have been drawn to the horrifying experiments of Nazi doctors; the specter of eugenics has once again been raised; and, reaching back even further, this recalls the ways in which scientific research allied itself with the imperialist project.

As future medical professionals, we must consider all of these things. But we must also consider the widespread ethical implications of international human subjects research and our roles as physicians. We will all conduct research, many of us abroad. And while the Guantanamo Bay detainees were a unique population, their situation has interesting parallels to other research subjects –international patients, populations that should be protected, or populations whose standard-of-care is lower than our own. The CIA fracas is an extreme example, a crystallization of these questions. It bothers us precisely because it summons the specter of our murky medical past.

PHR’s John Bradshaw interviewed on the organization’s allegations against the CIA: http://www.dailymotion.com/video/xdmt9q_cia-doctors-torture-assistance-inve_news

TODAY: Global HEALTH Act National Call-in Day

From Physicians for Human Rights:

Support the Global HEALTH Act (GHA). Call your Representative today and encourage them to co-sponsor the GHA.

As we celebrate the contributions of nurses worldwide, the health workforce crisis remains one of the greatest hurdles to realizing the right to health for all in developing countries. The GHA can help.

Introduced in Congress by Representative Barbara Lee in March, the GHA would provide $2 billion over five years to increase the number of doctors, nurses, pharmacists and other health workers in developing countries, and to improve primary health care for all.

The bill not only authorizes new resources, it also calls for the creation of a US Global Health Strategy that will complement the goals of developing countries and ensure our aid money is effectively used to save the lives of hundreds of thousands of people. Learn more about the bill on PHR’s blog.

It’s easy to take part in the Global HEALTH Act National Call-in Day. Call the Congressional Switchboard at (202) 224-3121 and ask to be connected to your Representative’s office (if you don’t know who your Rep. is, find out). Then, make your case. Use the script below, and/or bring your own experiences into the call:

Hi, my name is XXX and I live in Town, State. I am calling to encourage Representative XXX to co-sponsor HR 4933, The Global HEALTH Act, which will help fix broken health systems in developing countries. The Global HEALTH Act calls for the development of a US Global Health Strategy to harmonize aid, and provides $2 billion over 5 years to help countries in Africa hire, train and retain more doctors, nurses and other health workers. The Global HEALTH Act will save lives: I hope Rep. XXX will consider co-sponsoring this bill today.

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.