Archive for the 'Latin American Social Medicine' Category

Ebola in Liberia

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 Volunteers of International Medical Corps (IMC) suiting up in personal protective equipment (photo by J.M. Souers)

Volunteers of International Medical Corps (IMC) suiting up in personal protective equipment (photo by J.M. Souers)

MONROVIA, Liberia — Though the Ebola epidemic that put the world on edge may be waning in parts of West Africa, there is much more work to do be done to ensure this underserved region of the world does not continue to suffer from a potentially endemic and devastating disease.

From the start of the Ebola epidemic in West Africa there have been almost 10,000 reported deaths and 14,269 confirmed cases in Sierra Leone, Guinea and Liberia, according to the World Health Organization (WHO). The U.S. Centers for Disease Control and Prevention (CDC) was here in Liberia during the initial outbreak but pulled out in May thinking everything was under control. In August, months after the CDC left, the real Ebola crisis struck Liberia.

In January, I applied to Adventist Health International (AHI) to work as a volunteer physician at SDA Cooper Hospital in Liberia. The hospital is run as a general hospital that has been providing health services during the epidemic to patients that are not suspected of Ebola while screening and referring patients with signs of the illness to Ebola Treatment Units (ETUs).

On February 9, 2015, I arrived at the hospital in the capital city of Liberia. Upon arrival I learned of a confirmed case at our hospital that had been transferred to an Ebola Treatment Unit (ETU) just a few days earlier. The hospital now had to shut down the inpatient services for decontamination and everyone who had contact with the case agreed to be quarantined for 21 days as a precautionary measure. Since I did not have contact with the Ebola patient, I continued working at the hospital in the out-patient department and continuous infection control and prevention training.

The hospital was soon overwhelmed by representatives of the WHO, CDC, Medicins Sans Frontieres (Doctors without Borders), International Medical Corps and the Ministry of Liberia. In a semi-coordinated effort, representatives of the different organizations came to our hospital to offer their advice and services.  We were pleased to see that these organizations were finally giving our hospital assistance and aid, but staff was frustrated that the offer had not come earlier during the actual crisis.

The situation in Liberia is now finally starting to stabilize. There was a period of more than 25 days with no confirmed cases, according to sources at the CDC in Monrovia. Though, on March 19th a patient presented to Redemption Hospital in Monrovia and was confirmed positive on March 20th. It is rumored that the patient contracted the illness from Sierra Leone, not unlikely due to the very porous border between the two countries. Another theory is that the patient contracted the disease through sexual transmission from her partner over three months after he had been released from an ETU. This reality does not heed well for the already pronounced stigma towards survivors.

It is concerning that many organizations are already talking about decommissioning the ETUs to redeploy aid and services to Guinea and Sierra Leone, where the situation is much worse. There is no doubt that the epidemic must be further addressed in these countries to ensure the safety of Liberians and all of West Africa, but it is important to continue to support efforts in Liberia to eradicate the illness. The health system still needs major improvement to reduce the risk of an uncontrolled and devastating outbreak in the future.

Community leadership seems to have had the most impact on curbing this disease in Liberia. Recognition of the disease, plus changing traditional practices and customs was more widely accepted and accomplished in Liberia than in Sierra Leone or Guinea. This shows how important it is for healthcare organizations to work directly with community leaders at the local level, educating the general population to cooperate in changing habits and customs (i.e. burial customs, consumption of bush meat, hand washing and sanitation) that propagate such an infectious illness.

Education is critical, which is most apparent when working with hospital staff that has very little basic knowledge of infectious disease prevention and control. This is in part because we are in a country with extremely limited health infrastructure including hospitals without running water, dependable energy sources or proper waste management.  What does exist is hardly adequate to provide even some of the most basic health care needs of the population. It is a shame that an epidemic like Ebola was necessary to bring this to international attention.  It is even worse that the short-term solutions are almost exhausted and very few long-term solutions have been established.

Volunteer of International Medical Corps (IMC) working in hospital triage at SDA Cooper Hospital in Monrovia, Liberia (photo by J.M. Souers)

Volunteer of International Medical Corps (IMC) working in hospital triage at SDA Cooper Hospital in Monrovia, Liberia (photo by J.M. Souers)

Focus has turned towards effectively training health care workers in the hospital setting with the proper equipment and precautions for infection control and prevention. Transitioning care from the ETU setting back to the hospital setting has been aided by the “Keep Safe, Keep Serving” curriculum provided by the Liberian Ministry of Health.  Still, there are too few properly established hospital protocols to protect staff and patients from another outbreak. This creates insecurity for the hospital staff.  Proper onsite training, triage staff, laboratory testing, contact tracing teams, supply chain availability, international support and local community education are still needed to continue to address this transition.

The international community can help by not allowing this epidemic to be just another news flash.  Instead, they should make it their long-term mission to help developing countries create sustainable healthcare reforms and infrastructure for long-term outcomes.  Their incentive should be to limit the spread of communicable diseases like Ebola that are no longer confined to remote areas of the world given our new global economy.  Unless these diseases are recognized quickly and controlled effectively at their source, they can and may spread rapidly and become an international pandemic that threatens everyone.

Joanna Mae Souers is a medical doctor, native of upstate New York, and graduate of the Latin American School of Medicine in Havana, Cuba.

Cuba Leads the World in Lowest Patient per Doctor Ratio; How do they do it?

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by Joanna Mae Souers

*Paraguayan 5th year student participating in primary care in Havana, Cuba. (2011,by Joanna Mae Souers)

In early 2007, I began studying medicine at the Latin American School of Medicine in Havana, Cuba.  I entered the program not knowing much about the Cuban healthcare system, other than that it was universal and free.  “Now that’s a system I want to learn from,” I thought to myself, “It’s a system we could all learn from.”  Five years later, what have I learned?

There are many subtle and not so subtle differences between the Cuban and the U.S. health care systems which have allowed the Cubans to equal the U.S. with respect to their health statistics, but at a much lower cost and with better preventative and primary care.  In this paper I analyze just one of the reasons for the differences between the two systems; Cuba produces more primary care practitioners per capita.  How do they do it? Medical education in Cuba is free, all doctors interested in specializing must first serve two years working in primary care, and graduating doctors are not driven to specialize by salary incentives.  This socialist approach towards medicine and medical education assures the human resources necessary to provide universal and preventative healthcare to all.

People marvel at how Cuba has “accomplished so much with so little.”  And they marvel with good reason.  According to the World Health Organization, Cuba spent only $503 per capita on healthcare in 2009, the U.S. spent almost 15 times that sum.  In fact we in the US spent $421 per person just on the administration of the private healthcare insurance system, almost enough to fund the Cuban system. [1] [2] Despite dramatically lower costs, Cuba has some of the best health statistics and health indicators of any country around the world.

Although people like to compare and contrast the health statistics of the U.S. and Cuba, I think this a bit preposterous.  Cuba, a small island in the Caribbean, is being compared to one of the largest countries in the Americas with a very different history.  So in the table below, I have shown some health statistics on Cuba and the U.S. as well as the Dominican Republic and Haiti.  The Dominican Republic and Haiti are Cuba’s Caribbean neighbors; similar in size, history and geographic location.

*Statistical information provided by the World Health Statistics 2011 Report by the World Health Organization.

From this table, we can see that Cuba’s health indicators are more like those of the “first world” in the U.S. than its neighbors in the “third world.”  The life expectancy of the U.S. and Cuba is almost identical.  Cuba supersedes the U.S. in the categories highlighted.  So we continue to ask, “How do they do it?”  Could it have something to do with their philosophy that people need doctors?  Hence, their solution is to offer a free medical education to develop young, quality doctors dedicated to serving those in need.

Per capita Cuba graduates roughly three times the number of doctors as the U.S.   In 2005 Cuba had 70,594 doctors.  Before the revolution in 1959, there were only an estimated 6,000 doctors; somewhere around half left the country after 1959.  This means they must have graduated an average of 1,469 Cuban doctors per year, not including the some 5,000 international students who graduate each year from Cuban medical schools. [3]  When we later compare these numbers to the U.S. we see that Cuba graduates 3 times the number of doctors per capita, and the U.S. must import graduating doctors from other countries just to fill the primary care residency positions.

Critics of the “Obama Plan” say that there will not be enough doctors in the U.S. to take care of all the patients if everyone has healthcare coverage.  Obama encouraged the Association of American Medical Colleges to increase the number of graduating doctors by 30% in 2010.  Ever since 1980, U.S. Medical schools have graduated 16,000 doctors a year.  Meanwhile, the population of the U.S. has grown 50 million during the same period.[4]  A 30% increase would have meant we should have graduated 20,800 medical students in 2010, but we only graduated 16,838 according to the Kaiser Family Foundation.[5]  The number of residency programs at teaching hospitals in the U.S. has been frozen since 1997, funded by Medicare.  There were 29,890 residency slots filled in 2009,positions not filled by American graduates are filled by International Medical Graduates. [4]   This means we can estimate more than 1/3 of students in U.S. residency programs are International Medical Graduates (IMGs), students from another country or a U.S. citizen, like me, who studied in another country.

In the current scheme of things, International Medical Graduates are continuously brought in to the U.S. to meet the needs of the growing patient population.  Unfortunately nothing bridges the gap, because there just are not enough residency positions and/or funding for teaching hospitals to produce enough doctors to satisfy the entire U.S. population.  Taking International Medical Graduates to meet the needs of the U.S. population only adds to the “brain drain” of developing countries around the world.  So as we produce fewer doctors, introduce more doctors from other countries; U.S. doctors work harder for less to meet the needs in the U.S. and a lot of the world remains catastrophically underserved.

Cuba leads the world with the lowest patient to doctor ratio, 155:1, while the U.S. trails way behind at 396:1.[6]  With a surplus of Cuban doctors, Cuba is able to help ailing nations around the world.  They have medical missions in over 75 different countries lead by nearly 40,000 health professionals, almost half of them are doctors.[7]  The United States by contrast imports doctors from poorer countries, further contributing to the brain drain of professionals from poorer countries to rich ones.

In Cuba education is free.  Room and board, books and amenities are included.  Doctors are not burdened by student loans and live comfortably though not extravagantly.  Harvard Medical School states in their admissions statement that an “un-married first year medical student” will spend approximately $73,000 for the 2011-2012 academic year.  This includes tuition, room and board, books, etc.[8]  Now times that by four and you have a whopping $292,000 to shell out to become a Harvard doctor.  With interest rates, loan deferments and default charges, you might end up like Michelle Bisutti.  She graduated medical school in 2003 with a $250,000 debt, in which by 2010 had increased to $555,000.[9] This may be an extreme case, but the Association of American Medical Colleges projected in their 2007 report that in 2033, students on a 10-year repayment program will only see half of their after-taxes salaries, the rest going to loan repayment.[10]

The cost of medical education in the U.S. causes more and more medical school graduates to turn to higher paying specialties and subspecialties rather than primary care or family medicine.  Dr. Thomas Bodenheimer writing for the New England Journal of Medicine, stated that “between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent,” based on data from the National Resident Matching Program. [11]  In the U.S. specialists predominate at a ratio of 2:1 (the reverse of other Western countries) while half of all outpatient visits are made by primary care physicians. [12]   This deficit of primary care physicians decreases people’s access to primary care and preventative medicine, causing increases in health disparities and healthcare costs.  This is because preventative medicine benefits the patient as well as reduces the number of Emergency Department visits and hospital stays.  If there are no primary care physicians to provide preventative care to the population, we see the population suffer as costs continue to rise.

* Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates. From the American Academy of Family Physicians, based on data from the National Resident Matching Program. [11]

According to a survey in 2008 by the American Academy of Family Physicians, family medicine graduates with less than 7 years of experience earn, on average, a yearly salary of $145,000.[13]  The difference in earnings between primary care physicians and specialists differed by only 30 percent in 1980, and dramatically rose up to 300 percent for some narrowly defined specialists by 2009.  In the graph below, we show the dramatic difference between median compensation for selected specialties compared to that of primary care.[14,15]

*Median Compensation for Selected Medical Specialties.
Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005. [15]

When working in the U.S., almost every primary care physician I talk to has the same complaint, “Too many patients, and too little time.”  They are forced to see 20 to 30 patients a day just to meet pay-incentives and “keep their doors open.”  General/Family Practice physicians spend an average of 16.1 minutes with each patient per visit. [16]   Meanwhile, 18%, or roughly 48.2 million of the U.S. population under the age of 64 is without healthcare insurance.  They have no access to most GP’s or family practice physicians. [17]

We need to follow our Cuban role model, we need to be held socially accountable and produce more primary care physicians.  This can be accomplished by providing an education at full scholarship to those interested in primary care, or by increasing the number of medical students going into primary care by closing the compensation gap between primary care and the higher paid specialties.  These measures would ensure the population better access to quality primary care and preventative medicine.  It would bring down the cost of healthcare while allowing primary care physicians to practice under less stressful conditions leading to quality affordable healthcare for all.

 

  1. World Health Organization (WHO 2011); Countries. [www.who.int/countries/en]
  2.  “Healthcare Marketplace Project, Trends and Indicators in the Changing Marketplace (Exhibit 6.11: Private Health Insurance Admin Cost per Person Covered, 1986-2003),” Kaiser Family Foundation, Publication Number: 7031.  [http://www.kff.org/insurance/7031/print-sec6.cfm]
  3.  “Cuba and the Global Health Workforce: Training Human Resources.” Salud! (Source Vice Ministery for Medical Education and Research, Ministry of Public Health) [http://www.saludthefilm.net/ns/elam.html]
  4. Sullivan, Paul.  “Discomfort at U.S. Medical Schools.” The New York Times; April 29, 2009.
  5.  “Total Number of Medical School Graduates, 2010.”  The Kaiser Family Foundation.  [http://www.statehealthfacts.org/comparemaptable.jsp?ind=434&cat=8]
  6.  “World Health Statistics 2011,” World Health Organization; WHO Press, Switzerland.
  7. Brouwer, Steve.  “The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity,” Monthly Review, 2009, vol 60, issue 8 (January).
  8. Harvard Medical School Admissions, “Costs (Updated: 7/21/2011).”  [http://hms.harvard.edu/admissions/default.asp?page=costs]
  9. Pilon, Mary.  “The $555,000 Student Loan Burden,” The Wall Street Journal, February 13, 2010.
  10. Fuchs, Elissa.  “With Debt on the Rise, Students Face an Uphill Battle.” The Association of American Medical Colleges, January 2008.
  11. Bodenheimer, Dr. Thomas,“Primary Care – Will it Survive?” New England Journal of Medicine, vol 355;9. Pg 861-862.
  12. Alper, Philip R. “Primary Care’s Dim Prognosis,” Hoover Institution, Stanford University, Policy Review No. 158 (December 1, 2009).
  13. American Academy of Family Physicians, Income (2011).      [http://www.aafp.org/online/en/home/publications/otherpubs/debtmgmt/graduation/income.html]
  14. Alper, Philip R. “The Decline of the Family Doctor,” Hoover Institution, Stanford University, Policy Review No. 124 (April 1, 2004).
  15. Woo, Dr. Beverly.  “Primary Care – The Best Job in Medicine?” New England Journal of Medicine, vol 355;9. Pgs 864-866.
  16.  “Healthcare Marketplace Project , Trends and Indicators in Changing Healthcare Marketplace (Exhibit 6.5: Mean Time Spent with Physicians (in Minutes), 1989 – 2002),”  Kaiser Family Foundation, Publication Number: 7031, Information Updated: 4/11/05.      [http://www.kff.org/insurance/7031/print-sec6.cfm]
  17.  “2010 National Health Interview Survey (Tables 1.1A-B, 1.2 B)”, Center for Disease Control.  [http://www.cdc.gov/nchs/fastats/hinsure.htm]

 

Door-to-Door; Dengue Fever

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Medical Students and community members participate in dengue fever prevention efforts in Havana, Cuba (photographer, Joanna Mae Souers)

January, classes were suspended for medical students throughout Havana.  The dengue epidemic had reached its height and health officials decided it was time students joined the prevention efforts; door-to-door.  It is not the first time.  Medical students in Cuba have frequently been called upon for their volunteer services and solidarity to the community during epidemics and medical emergencies including Hurricane Katrina and the Chernobyl Disaster, political campaigns including “Bringing Home Emilio” and “Free the Cuban Five” and interests of state like harvesting potatoes and planting citrus trees.

When we first hit the streets we were armed with knowledge of disease prevention and assigned individually or in pairs to a city block.  We were oriented to visit each household daily, talk to each family about dengue prevention, teach signs and symptoms, and remit anyone in the home with fever to their local health center.  We were also given instructions to enter the homes, revise water tanks, and dispose of any items that could serve as fresh water containers where mosquitoes deposit their eggs.

On my own city block I had seen several issues solved and few to be addressed.  For example, I successfully mapped out the community and spoke face-to-face with at least one member of every household.   People were very cooperative and happy to receive us in their homes.  It was most important to see if anyone had come down with a fever or noticed any problems in the community concerning vector control and focal points where water was collecting and mosquitoes could be potentially breeding.

Most Cubans are well educated on the signs and symptoms of dengue and the methods of prevention.  Even before we speak to them, they have already heard the information from their local nurses, doctors, door-to-door inspectors, schools, community meetings, television, radio, and newspapers.  We may not have any new information to transmit to them, but we are able to bring to their awareness the severity of the epidemic and the importance of their continued cooperation in further prevention efforts by creating a presence in the streets.

The student efforts were so important because specialists were concerned that if the numbers did not return to a record low by the time the rains came in March, the epidemic would be out of control and cost many more lives.  Thanks to the students and the cooperation of the community our prevention efforts made a difference and progress was made just by going door-to-door.  The number of cases around the city steadily declined as cases were reported and prevention efforts were enforced.  The campaign lasted just a month, and in February with the epidemiologists satisfied and the community safe from dengue, we were on our way back to classes.

Steve Brouwer, author of Revolutionary Doctors, will discuss health care in Venezuela and Cuba on 9/2/11 in NYC.

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Steve Brouwer

Readers of the Portal may be interested in a talk this Friday (9/2/2011) at the CUNY Graduate School.  Steve Brouwer, author of the blog Venezuela Notes, will be speaking about his new book, Revolutionary Doctors published by Monthly Review Press.   He will be accompanied by the Honorable Jorge Valero Briceño, Permanent Representative of the Bolivarian Republic of Venezuela to the United Nations.  The talk will take place at 7PM at the Elebash Recital Hall, The Graduate Center, CUNY, 365 Fifth Avenue, New York, NY 10016.  Click here for a flyer.

Brouwer’s book begins with a discussion about the Cuban medical system and its programs of medical internationalism (either providing medical care directly overseas or training foreign doctors).  It goes on to consider how Cuba assisted Venezuela to create a new public health care system, known as Barrio Adentro.  Finally, Brouwer looks at the backlash against the Cuban model on the part of the US as well as the development of revolutionary medicine as part of the creation of a socialist society.  It is always mind opening to read about serious attempts to construct socialist societies; there are real alternatives to our current social structure.

Brouwer notes that medicina integral (comprehensive or whole medicine) is built on Che Guevara’s idea that “individuals can liberate and develop themselves more fully when they are devoted to the full and revolutionary development of their communities and societies…”   This conception of human development stands in stark contrast to current US political discourse where we are told that individuals develop most fully when they are disconnect from the broader social good and pursue their own selfish ends.

Readers who want some background on Venezuela prior to the talk may want to look at several articles published in our journal Social Medicine.  Rebecca Trotsky-Sirr described her experiences with Barrio Adentro in Adentro Barrio Adentro: An American Medical Student in Venezuela and Carlos Muntaner and colleagues discussed the evolution of  Barrio Adentro in Venezuela’s Barrio Adentro: participatory democracy, south-south cooperation and health care for all.

Finally, it is always worth remembering that Cuba’s medical internationalism extends to the US as we have discussed in prior postings about free medical education for US citizens in Cuba.

The talk is presented by  Monthly Review Press; Bolivarian Circle Alberto Lovera; Cuba Solidarity New York; TheIndypendent; July 26 Coalition; Casa de las Americas; The Center for the Humanities at The Graduate Center, CUNY; IFCO-Pastors for Peace; The Center for Place, Culture and Politics, CUNY; and others.

posted by: Matt Anderson

Chile: A Year After the Earthquake – Educación Popular en Salud (EPES) Fundraiser, February 25th, 2011

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Action for Health North America works in solidarity with Educación Popular en Salud, a Chilean-based group promoting community health.  With 29 years of experience in Chile, EPES responded immediately to the devastating earthquake and tsunami of February 27, 2010. Come hear about the unique role EPES undertook to sustain people in Concepción immediately following the disaster, and their long-term efforts to help people who lost everything rebuild their homes, their lives and their communities.

For more information about this event (venue and time), please contact: Dr. Marcelo Vanegas.

Here is a video about EPES’ response to the earthquake:

Posted by Matt Anderson, MD

ELAM Students & Graduates Work with Cuban Doctors in Haiti

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I requested a year off from school to go to Haiti and work with the Cuban doctors after completing my 2nd semester of 3rd year at ELAM (the Latin American School of Medicine). I am one of 120 American citizens studying medicine in Cuba free of charge, with plans to practice medicine upon graduation in underserved communities of the United States and around the world.

When I arrived, I found several international ELAM graduates (http://elamedicosinternacionalistas.wordpress.com), including 7 United States graduates (http://www.michaelmoore.com/words/mike-friends-blog/cuban-trained-us-docs-complete-haiti-mission), and a number of Haitian medical students working alongside the Cuban doctors. We were stationed at a field hospital set up by the Henry Reeve Brigade of Cuban doctors on January 28th in a small central park of Croix des Bouquet, just outside Puerto Prince. Together we served displaced earthquake victims and patients suffering from inadequate health care services.

In the first six months the hospital was established, we addressed the needs of more than 70,312 patients; 53,588 at the hospital and 16,723 in the field. We performed a total of 2,506 operations on-site, with 786 major surgeries; including emergency caesarean sections, ectopic pregnancies, thyroidectomy, hernias, hydroceles, hysterectomies of uterine fibroids, orthopedic surgeries and more. We assisted 116 natural births. We diagnosed 3,533 patients with our on-site laboratory and diagnostics center. We saw 3,192 patients for x-rays and ultrasounds. We treated 8,778 patients with physical therapy, and we hospitalized 2,053 patients on-site (Information provided by the Henry Reeve Brigade of Croix des Bouquet Statistical Report, June 2010).

When you stepped out of the hospitals and into the streets the only question that came to mind had to be, “where is the aid?” It was obvious, even six months after the earthquake that little progress had been made, with little to no evidence of monetary support. Hundreds of thousands of people were still living displaced in make-shift tent cities. The city still resembled a disaster zone with buildings teetering above cracked foundations, while corpses remain beneath the rubble. The doctors seemed to be the only relief effort making a difference.

The Cuban doctors were accomplishing more than what the international community was willing to recognize. Croix des Bouquet was just one of several field hospitals established by the Henry Reeve Brigade to serve communities in and around Puerto Prince free of charge. CNN even had to apologize after interviewing one of the Cuban doctors and crediting him as Spaniard. Fortunately, Cuban doctors aren’t looking for recognition; they are out to save lives and continue to do so all over the world.

The Henry Reeve Brigade has since moved on to other emergencies, like the fires plaguing Russia. Other Cuban doctors have replaced them to continue serving the Haitian community free of charge. Brazil and Cuba have signed a trilateral accord with the Haitian Health Minister to establish three hospitals staffed by Cuban doctors located in communities surrounding Puerto Prince where health services are limited to non-existent. Cuba has been dedicated to sending doctors to Haiti for 11 years. Amidst the unfortunate circumstances of the earthquake, they continue to fulfill their commitment to the Haitian community by sending doctors. With the success of the students working alongside the doctors, they now have plans to send more students in the years to come.

Note: Article written by Joanna Mae Souers. Photograph titled, “Joanna Mae Souers on Wound Care” was taken by Cuban photographer, Juvenal Balán. The other photographs were taken by Joanna Mae Souers.

New issue of Social Medicine (V4N3) Just Published

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Social Medicine, our open-access, online academic journal has just published its latest issue. Here is a brief summary of the articles all of which are available for free at www.socialmedicine.info and www.medicinasocial.info (in Spanish).

Children in post-Civil War Nepal singing revoutionary songs

Children in post-Civil War Nepal singing revoutionary songs

Special Theme: Social Medicine & War

For this special theme issue on Social Medicine & War, Dr. Vic Sidel served as guest editor. His lead editorial (co-authored with Dr. Barry Levy) examines the diversion of resources to war and the preparation for war.

Quoting from their introduction to the three original research articles about war, Drs. Sidel and Levy write:  “Dr. Andrea Angulo Menasse, a researcher from Mexico City’s Autonomous University, documents the very personal story of how the violence of the Spanish Civil War affected one family. In her case study the trauma suffered by Spanish Republicans is traced through three generations and crosses the Atlantic Ocean as the family moves is exiled in Mexico. Dr. Sachin Ghimire from the Centre of Social Medicine and Community Health of the Jawaharlal Nehru University reports on his fieldwork in Rolpa, Nepal, the district from which the Nepal Civil War (also called the People’s War) originated in 1996. Based on 80 interviews, he documents the difficulties faced by health care workers as they negotiated the sometimes deadly task of remaining in communities where control alternated between Nepalese Special Forces and the Maoist rebels. Finally, Colombian researcher, Carlos Iván Pacheco Sánchez, from the University of Rosario in Bogota, brings an epidemiologist’s tools to examine the impact of the ongoing armed conflict in the border Department of Nariño. His discussion is informed by the current debate over health care in Colombia where a recent Constitutional Court decision has found that the current health care system violates the right to health.”

Closing the Gap: Where are we one year later

a87ad0d1a8In August of 2009, the WHO’s Commission on the Social Determinants of Health issued a bold call to eliminate health disparities within a generation. Three articles in this issue look at what has – and has not – happened in the intervening year. Our second editorial examines the international response to the Commission’s call. José Carlos Escudero explores the meaning of the report for the WHO and underscores the report’s limitations. A detailed critique of the report, along with an alternative approach to addressing health inequities, is offered by Dr. Anne-Emanuelle Birn. Dr. Birn’s critique is especially important for offering important historical background by exploring how Europeans in the 19th century – notably Louis-René Villermé, Edwin Chadwick, and Friedrich Engels – each approached the social disparities that arose during the Industrial Revolution.

The Peckham Experiment

peckhamhealthcentreWe are also very pleased to publish three classic texts describing the Peckham Experiment, an innovative community center built in England during the Depression. The Pioneer Health Center was designed around the idea of studying (and fostering) what makes people healthy, rather than what makes them sick. Imagine that!

Please visit the journal and explore the breadth, depth and scope of social medicine past and present. Along with some suggestions for the future.

posted by Matt Anderson, MD

Update on Honduran physician Luther Ware & Garifuna Hospital

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We have received the following update from MEDICC about the situation at the Garifuna Hospital in Honduras.  We feel it’s important to keep international attention on the situation in this hospital, particularly since the US government’s anemic response to the June 28th coup has been criticized in an 8/11/2009  New York Times Op-Ed piece as providing further evidence of “Obama’s failure in the hemisphere.”

Garifuna HospitalAugust 11 – Despite objections by local Garifuna communities, Honduras’ defacto government is moving to take over the first and only Garifuna-managed hospital in the country, ousting its current staff. The facility-built by Dr. Luther Castillo, other Garifuna doctors, local architects, and the communities themselves-is located in the remote coastal municipality of Iriona.

Last week, says Dr. Castillo, the defacto ministry of health notified hospital staff that the facility was being downgraded to a health center “under new management”. “They told us that the Garifuna staff-both doctors and locally-trained nurses aides-will be fired,” he told MEDICC. “These measures would condemn to death many of our old and seriously ill people, and stop all outreach and prevention services.”

However, he said the staff is staying put, and vows to continue working, even without the small stipend the government had provided in the past and with no guarantee of medicines or vital supplies.

“We will not abandon our people,” said Dr. Castillo. “These are the poorest of the poor, the invisible poor.. They are the real victims of the coup,” he told MEDICC.”And they are the reason so many of our young people decided to become doctors in the first place.”

Some 300 representatives of local Garifuna governments gathered last week to support the hospital and its staff, and have declared they will not recognize the defacto government’s takeover move.

The Garifuna hospital officially opened in December 2007, under an agreement with the government of President Manuel Zelaya, and in accordance with an International Labor Organization covenant that supports locally-managed health services for indigenous and tribal peoples. Since then, according to Dr. Castillo, the ten Garifuna doctors staffing the hospital have treated over 175,000 cases. The physicians-all graduates of the Latin American Medical School in Havana-attend patients at outlying clinics and on regular home visits. The original government agreement permitted this medically underserved region to rely on hospital services, including birthing, surgeries, hospitalization, dental care and laboratory tests.

Dr Luther WareSince 1999, Luther Castillo has directed the Luaga Hatuadi Waduheñu Foundation (“For the Health of our People” in Garifuna), dedicated to bringing vital health services to isolated indigenous coastal communities. After his 2005 graduation from the Latin American Medical School in Havana, Dr. Castillo returned to the Honduran coast, where he led construction of Honduras’ first Garifuna Rural Hospital, now serving some 30,000 in the surrounding communities. The hospital opened in December 2007, just months after Dr. Castillo was named “Honduran Doctor of the Year” by Rotary International’s Tegucigalpa chapter. “Thank you for inspiring me,” said California Lieutenant Governor John Garamendi, speaking at the hospital’s opening ceremony.

The hospital and its community health outreach are supported by a number of U.S. and other international organizations, including the Sacramento, California Central Labor Council, Global Links, The Birthing Project, and MEDICC.  Several US medical schools also have cooperative arrangements with the Garifuna hospital, including Johns Hopkins, Emory, Charles Drew and University of California (SF). Eight Cuban physicians and nurses also provide specialized services and academic training at the hospital.

A few weeks before the coup, Dr. Castillo was named director of International Cooperation in the Honduran Foreign Ministry. Since July 3rd, he has been included on a list of persons whose lives and safety were declared “at risk” by the OAS Inter-American Commission on Human Rights.

Take Action Now:

MEDICC is joining other U.S. organizations such as Global Links (www.globallinks.org) to stand with the staff and over 30,000 patients of the only Garifuna Community Hospital in Honduras.

Here’s what you can do:

1) DONATE to keep the hospital alive.  Your donation to Honduras’ First Garifuna Hospital will help pay small stipends to physicians and nurses’ aides, and help stock the hospital with essential medicines and supplies. (Donate Here)

2) SPEAK UP! Take this message to your city council, labor union, student or professional organization, asking them to pass a resolution in support of the Garifuna Indigenous Hospital in Honduras. Send these resolutions to us, and publicize them in your local media and on the web.

3) GET READY TO GO on a delegation to Honduras as a “Witness for Health” to help guarantee the safety and rights of the Garifuna hospital staff. More information coming soon..

4) Urge the US government to act: Contact the White House, the State Department and your Congressional representatives. Press them to use the US government’s influence to guarantee respect for the lives of Dr. Castillo, his colleagues and all those protesting the coup. State Department: 202-647-4000 or 1-800-877-8339. White House: Comments: 202-456-1111, Switchboard: 202-456-1414

Contact your Senators here: www.senate.gov/general/contact_information/senators_cfm.cfm

Contact your Congresspeople here: https://writerep.house.gov/writerep/welcome.shtml

5) Keep Honduras in the public eye: Circulate this alert widely. GO ON THE WEB: use your blogs, listservs and networks to get the word out.

posted by Matt Anderson, MD

Update on Dr. Luther Castillo & the Honduran coup

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From US Medical Student Joanna Mae Souers & MEDICC:

luther_castilloDr. Luther Castillo is a dear friend of mine… he is doing amazing things as a doctor in Honduras, and now that the world has turned it’s back, he’s trying to shed light on the situation…

He asked us to thank all of you for defending the lives of Hondurans threatened by the coup. He is spending some hours most nights attending to wounded or to families housed in temporary shelters throughout Tegucigalpa. He moves around, doesn’t sleep in one place. The streets after dark, he says, are “completely militarized”.

He reports that the defacto government is attempting to stop demonstrations and continued strikes by teachers and others, selectively targeting their leaders using a growing “hit list” of names that include his own. He says the attacks are being carried out by the army or by “criminals-for-hire”, reminiscent of the death squads of the 1980s. Three grassroots and labor leaders have been assassinated in the last few days alone.

Dr. Castillo has two main concerns:

ONE: the international press blackout on Honduras, with virtually all media either shut down or expelled. “We can’t let silence win; we need your voices,” he said.

TWO: the fate of the only Garifuna Hospital in Honduras, now without government support. Located in Ciriboya, the hospital is staffed by the group of young Garifuna doctors who founded it, working with volunteer Cuban physicians. Dr. Castillo reports they are down to their last supplies and medicines for 20,000 people living in the surrounding indigenous communities, settlements with no lights or running water.

“These are the poorest of the poor, the invisible poor. They are the real victims of the coup,” Dr. Castillo told MEDICC.

TAKE ACTION NOW!

Urge the US government to act: If you haven’t contacted the White House, the State Department or your Congressional representatives, DO SO NOW. Press them to use the US government’s influence to guarantee respect for the lives of Dr. Castillo, his colleagues and all those protesting the coup, and to ensure the return of Honduras’ elected government. State Department: 202-647-4000 or 1-800-877-8339. White House: Comments: 202-456-1111, Switchboard: 202-456-1414

Contact your Senators here: www.senate.gov/general/contact_information/senators_cfm.cfm

Contact your Congresspeople here:

https://writerep.house.gov/writerep/welcome.shtml

Keep Honduras in the public eye: Circulate this alert widely. GO ON THE WEB: use your blogs, listservs and networks to get the word out. Write a letter to the editor of your local newspaper.

There are also several Facebook groups that you can also join/post on:

http://www.facebook.com/group.php?gid=96870380185

http://www.facebook.com/group.php?gid=102246697300

http://www.facebook.com/againstcoup?ref=s

http://www.facebook.com/group.php?gid=95487307148

If you are a health worker or professional: ask your union, society or organization to post this alert and issue a public statement defending the rights and lives of your colleagues in Honduras.

Donate to the Garifuna Hospital: Global Links in Pittsburgh, Pennsylvania, has sent several containers of equipment and supplies already.  They will make your donation count for more.  Log on to: www.globallinks.org

Donate to MEDICC’s program to support the Garifuna medical students and graduates of the Latin American Medical School.

For more information and actions you can take, go to:

Latin America Working Group– www.lawg.org

Center for Democracy in the Americas www.democracyinamericas.org

Here is more information you can use:

Since 1999, Luther Castillo has directed the Luaga Hatuadi Waduheñu Foundation (“For the Health of our People” in Garifuna), dedicated to bringing vital health services to isolated indigenous coastal communities. After his 2005 graduation from the Latin American Medical School in Havana, Dr. Castillo returned to the Honduran coast, where he led the Foundation’s construction of Honduras’ first Garifuna Rural Hospital, now serving some 20,000 in the surrounding communities.

The hospital opened in December 2007, a few months after Dr. Castillo was named “Honduran Doctor of the Year” by Rotary International’s Tegucigalpa chapter. “Thank you for inspiring me,” said California Lieutenant Governor John Garamendi, speaking at the hospital’s opening ceremony.

The hospital and its community health outreach are supported by a number of U.S. and other international organizations, including the Sacramento, California Central Labor Council, Global Links, The Birthing Project, and MEDICC.  Several US medical schools also have cooperative arrangements with the Garifuna hospital, including Johns Hopkins, Emory, Charles Drew and University of California (SF).

Just weeks before the coup, Dr. Castillo was named director of International Cooperation in the Honduran Foreign Ministry.

Dr. Castillo is featured in ¡Salud! (www.saludthefilm.net), a documentary film that received the Council on Foundations Henry Hampton Award for Excellence in Film & Digital Media (USA).

MEDICC (Medical Education Cooperation with Cuba), www.medicc.org, is a US non-governmental organization working to enhance cooperation among the U.S., Cuban and global health communities aimed at better health outcomes.



Joanna Mae Souers
Escuela LatinoAmericana de Medicina
Carretera Panamericana
KM 3,5
Santa Fe, Playa
Ciudad de la Habana, CUBA
CP 19108

Social Medicine Volume 4 Number 2: Economic Crisis, Social Determinants, Participation & more

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We have just published a new issue of Social Medicine/Medicina Social, our bilingual, online journal.  It is available in both English and Spanish.  Our 13th issue touches on several important issues in world health including the current economic crisis and the WHO Commission’s on the Social Determinants of Health.  And, of course, the stories of activists like the young US students (shown below) studying medicine at the Latin American Medical School (ELAM) in Havana.  They will be traveling in the Southwest US this summer to discuss their experiences with the American Indian community:

SSWE group shot (7 x 3)

The Economic Crisis and Public Health

Barry S Levy, Victor Sidel

The current global economic crisis seriously threatens the health of the public. Challenges include increases in malnutrition; homelessness and inadequate housing; unemployment; substance abuse, depression, and other mental health problems; mortality; child health problems; violence; environmental and occupational health problems; and social injustice and violation of human rights; as well as decreased availability, accessibility, and affordability of quality medical and dental care. Health professionals can respond by promoting surveillance and documentation of human needs, reassessing public health priorities, educating the public and policymakers about health problems worsened by the economic crisis, advocating for sound policies and programs to address these problems, and directly providing necessary programs and services.  Full Text: PDF

An Interview with Sir Michael Marmot

The Editors

In August of 2008 the WHO Commission on the Social Determinants of Health concluded its work with the publication of a report entitled: “Closing the gap in a generation: Health equity through action on the social determinants of health.” The Commission’s chair, Sir Michael Marmot, was kind enough to answer our questions about the Commission’s recommendations. This interview was conducted by email in May of this yea

Social Medicine: We congratulate the Com-mission on its excellent work in bringing attention to the social determinants of health and the Commission’s call for health equity. We appreciated the Commission’s recognition that: “Social Justice is a matter of life and death.” We were also happy that the Commission included representatives of civil society in their work. This was an important affirmation of democratic values.
When thinking about health inequalities people often use the analogue of the ladder to show how the gradient of worsening health outcomes affects all people in society except (presumably) those at the very top. Thinking about the ladder leads us to pose the following question: Is making the ladder shorter (i.e. reducing inequalities) the only approach to inequalities or is it possible to imagine making the ladder disappear entirely?

Sir Michael Marmot: All societies have hier-archies. It is not conceivable, therefore, to have a society with no ladder. The conceptual framework of the Commission on Social Determinants of Health leads us to think of at least two (linked) ways to address the relation between position on the ladder and health: act at the societal level to reduce social inequalities, and break the link between position in the social hierarchy and health.

The first argues for reducing the slope of the social gradient. To see this, suppose, just for a moment, that the ladder were defined on the basis of years of education. People who had three years or fewer had life expectancy of 50 years, those who had 13 years or more had life expectancy of 80 and the rest were ranged in between in a graded way: the social gradient in health. Now if we had a societal change so that everyone had at least 10 years of education, and better health followed as a result, the magnitude of health inequity would be reduced. We have reduced inequities by making the ladder shorter. […]Full Text: PDF

Participation and empowerment in Primary Health Care: from Alma Ata to the era of globalization

Pol De Vos, Geraldine Malaise, Wim De Ceukelaire, Denis Perez, Pierre Lefèvre, Patrick Van der Stuyft

With the 1978 Alma Ata declaration, community participation was brought to the fore as a key component of primary health care. This paper describes how the concepts of people’s participation and empowerment evolved throughout the last three decades and how these evolutions are linked with the global changing socio-economic context.

On the basis of a literature review and building on empirical experience with grass roots health programs, three key issues are identified to revive these concepts: The recognition that power, power relations and conflicts are the cornerstone of the empowerment framework; the need to go beyond the community and factor in the broader context of the society including the role of the State; and, considering that communities and society are not homogeneous entities, the importance of class analysis in any empowerment framework. Full Text: PDF

Latin American Social Medicine and the Report of the WHO Commission on Social Determinants of Health

RAFAEL GONZALEZ GUZMAN

In October 2008 the Latin American Social Medicine Association (ALAMES) organized an international workshop entitled “The Social Determinants of Health.” Representatives of ALAMES’ seven regions participated in discussions of the various consultative papers prepared by the working groups of the WHO Commission on the Social Determinants of Health as well as the Commission’s final report. The workshop considered how ALAMES should respond to the work of the Commission. In this paper we summarize the main points outlined in the position paper prepared by the Organizing Committee1 as well as a synopsis of the main contributions made by each of the workshop’s study sections.  Full Text: PDF

For the full Table of Contents visit: http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/issue/view/38/showToc

posted by Matt Anderson, MD




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