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Imprint

Editor in Chief Bronwyn Jones, Australia

Design/LayoutHassan Aboul-Nour, EgyptEbraheem Mousa, EgyptAirin Aldiani, IndonesiaErick Melendez, El SalvadorOmar H. Safa, Egypt

Content EditorsMariam Parwaiz, New ZealandRami Abdallah, EgyptHelena Chapman, Dominican

RepublicPunyahari Dahal, NepalAhmad Jawad Mufti, Pakistan

Photography EditorsMohamed El-Sherbeny, EgyptHassan Aboul-Nour, EgyptZiad Elsamdony, Egypt

ProofreadingBetty Huang, TaiwanKingsley Njoku, NigeriaEman Ismail, Egypt

Angeline Yeap, Malaysia

Publisher International Federation ofMedical Students’ AssociationsGeneral Secretariat:IFMSA c/o WMAB.P. 6301212 Ferney-Voltaire, FrancePhone: +33 450 404 759Fax: +33 450 405 937Email: [email protected]

Homepage: [email protected]

This is an IFMSA publication© Portions of this publication may bereproduced for non political, and nonprofit purposes mentioning the sourceprovided.

Disclaimer This publication contains the collectiveviews of different contributors, theopinions expressed in this publicationare those of the authors and do notnecessarily reflect the position of IFMSA.

The mention of specific companies or ofcertain manufacturers’ products does not

imply that they are endorsed orrecommended by the IFMSA inpreference to others of a similar naturethat are not mentioned.

Notice: All reasonable precautions havebeen taken by the IFMSA to verify theinformation contained in this publication.However, the published material is beingdistributed without warranty of anykind, either expressed or implied. Theresponsibility for the interpretation anduse of the material lies with the reader.In no event shall the IFMSA be liable fordamages arising from its use.

Some of the photos and graphics usedare property of their authors. We havetaken every consideration not to violatetheir rights

IFMSAThe International Federation of Medical Students’ Associations

(IFMSA) is a non-profit, non-governmental and non-partisan

organization representing associations of medical students

internationally. IFMSA was founded in 1951 and currently

maintains 108 National Member organizations from more

than 100 countries across six continents with over 1,2 million

students represented worldwide. IFMSA is recognized as a

non-governmental organization within the United Nations’

system and the World Health Organization and as well, it

is a student chapter of the World Medical Association. For

more than 60 years, IFMSA has existed to bring together the

global medical students community at the local, national and

international level on social and health issues.


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C o n t e

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Editorial

Words from the Editor in Chief

President’s MessageMessage from the IFMSA President

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Follow the DreamMessage from the MSI Layout Design Co-ordinator4

21SCORAliciousWelcome to the world of the SCORAngels

The SCORPionLearn about Human Rights and Peace efforts worldwide

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61

The SCOPHianMeet SCOPHeroes who save the day through their Orange Activities.49

SCOREviewHave you ever wondered what SCORE exchanges are all about?

SCOMEdyThe guardians of medical education share their stories

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periSCOPEGo travelling with SCOPEans on their professional exchanges83

Advocacy and the Physician in TrainingArticles on the theme of the March Meeting 20136Projects BulletinRead about IFMSA’s local, national and transnational projects

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Dear IFMSA Family,Nowadays it’s difficult to go through university,

let alone life, without advocating for a cause. Weare all advocates in one way or another.

As medical students we have a moral responsi-bility to keep ourselves abreast of healthcare issuesaffecting humanity today. It is through educatingourselves that we become passionate about causes,and in the process, learn how to champion for them.

I honestly believe that the IFMSA is a fantas-tic platform upon which we can learn to becomehealthcare advocates, in the truest sense of the word.Our General Assemblies, projects and trainings arejust some of the many examples of advocacy workbeing organised and orchestrated by our medicalstudent leaders today.

This edition of the Medical Student Internationalis unique in that it is our first “integrated” publica-tion, comprising articles not just on the theme of theMarch Meeting but also from the Projects Support

Division and the 6 Standing Committees. I knowthat readers perusing the pages of this magazine

will find plenty of inspiration for advocacy work, asI have personally read each article within its pages.

It is my sincere hope that you will refer to thismagazine in the years to come, whether it be for afresh dose of inspiration or a bit of light reading. ThisMSI is a tribute to all those who strive towards theideal of Health for All.

I wanted to take the opportunity to thank ev-

eryone who has been involved in producing thisWonderful publication, from my own IncredibleInternational Publications Team to all of theAwesome authors and Excellent editors of the indi-vidual publications contained within.

Again, special thanks go to my Wonderfulteam. In alphabetical order: Ahmad, Airin, Betty,Eman, Erick, Hassan, Helena, Hima, Ismail, Khalid,Kingsley, Mariam, Mohamed, Punyahari and Rami.I love you all!

With my love and best wishes always,

Bronwyn.

Bronwyn Jones,Publications Support DivisionDirector 2012-2013

Editorial

Dear IFMSA fellows and MSI readers through-out the globe,

First allow me the honor of expressing my sin-cere gratitude to the great team working with me:Bronwyn, Airin, and Hima. I would also like to thankMr. Omar Safa, our former Publications SupportDivision Director, who was responsible for oversee-ing the design of the template for this amazing pieceof art.

The saying that MSI is, “the voice of medical stu-dents from the dunes of the Sahara to the icebergs

of the Arctic”, is something I heard the day I joinedIFMSA five years ago. Ever since then, it has beenmy dream to write an introduction for this publica-

tion. Now my dream has come true, so I have asimple request from each and every one of you dearfellows: do all you can to make your dreams cometrue.

May you enjoy the words of our fellow studentscontained throughout the pages of this great MSI!

Peace be upon you,Hassan

Hassan Aboul-NourMSI Layout Designer

Follow the Dream

4 www.ifmsa.org

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Dear IFMSA members and associates,

It is with great excitement that I write to you inthis special edition of MSI, highlighting the workand issues most important to our members, acrossall our activities.

This special issue is also one that touches the veryhearts and souls of many of our members because ofits theme, “Advocacy and the Physician-in-Training”.

Some of us realized that spark in us to becomeleaders of social change early on in our lives—some-times through the volunteer work we have done inour communities, schools, churches and other civilorganizations—and have always strived to be partof a group of like-minded people that share a visionof a better world—and IFMSA was destined to be apart of our pathway as future doctors. Others of usstumbled upon IFMSA by chance and curiosity forthe unknown, either through an attractive invitationto an exotic destination or through participation inexchange. Some of us have very unique stories ofhow IFMSA discovered them. Whichever pathway

it may be, IFMSA challenges us to take on a moreactive role—more often the role is being an advo-cate or an individual that works toward achievingsomething they believe in.

Now, IFMSA and AMSA have been affordeda unique opportunity to share their knowledgeand experiences, in one setting— at this GeneralAssembly —and focus on the theme of Advocacyand the Physician-in-Training.

IFMSA over the years has brought togethermedical students from around the world to ex-

change ideas, build capacity, create projects andcampaigns, and most importantly capture the voiceof medical students on health issues.

Recently, IFMSA has been increasingly con-necting medical students and their actions with theglobal health governance arena. In this past yearonly, IFMSA has participated in key internationalhealth events— COP18, IAC, WHS, WHO Meetingsand General Assemblies, and many more. Wealso are engaging in discussions on the Post-MDG2015 Agenda, Climate Change, and UniversalHealth Coverage, Access to Research and EssentialMedicines, Gender and Sexuality Issues, Women’sHealth, Social Determinants of Health and Human

Resources for Health. However, there are manyother issues, such as Mental Health, Persons withDisabilities, Health Promotion, Conflict Situations,Road Safety, Violence Reduction, Substance Abuseand many more that IFMSA can do more on.

Despite these recent developments, IFMSA hasstayed committed to its grassroots origins. IFMSAhas promoted information exchange and culturalunderstanding through its more than 10,000 annualclinical and research exchanges. IFMSA is continu-

ally building skills and knowledge through peereducation, trainings and workshops. IFMSA takesan active role in reaching out to both non-repre-sented and represented areas of the world throughnational member organization (NMO) outreach.IFMSA’s project culture is thriving — the divisionsupports the work of NMOs, transnational projects,and initiatives. Our health promotion campaigns onissues such as International AIDS Day and WorldDiabetes Day continue to increase awareness at thelocal level.

Advocacy and Physicians-in-Training

Young people make up the majority of theworld’s population and we will bear the greatestburdens of society, thus it is in our interest to be apart of the solutions proposed to address the great-est health issues, as future physicians.

As we focus on the theme of Advocacy and thePhysician-in-Training, let’s take a moment to reflectupon our role in being an advocate of issues af-fecting the health and well being of people. It isyour responsibility on how you take the knowledgeand opportunities afforded to you to address thosesocial issues affecting your communities around the

world.

AcknowledgementsI would like to give a special thanks to all those

that have taken the time to create and contribute tothis very special edition of MSI—thank-you for beingpart of the change!

I wish all of you a wonderful meeting and maywe all continue to take on the health challenges ofthe 21st century, as leaders, together!

Sincerely,

President’s Message

Roopa Dhatt,IFMSA President 2012-2013

medical students worldwide | USA MM13 5

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Efforts made to reduce resident work hours in TaiwanA wave of shock swept over Taiwan one evening in 2011.“A medical intern, Yeng-Ting Lin, was discovered dead ina bathroom after 36 successive hours of work on April27th. Investigations are being done to confirm whether hisdeath was due to overwork.” The correspondent on televi-sion went on, “According to a study, overworked doctorsare no more sober than a drunk person! If the situationdoes not improve, who is going to guarantee that you arenot the next one to suffer from medical errors made byoverworked doctors?”.

During the previous three years in Taiwan, 9 cases ofdoctors dying from being overworked had already beenreported. But it was only after the tragic event of the internon April 27th that the general public became aware ofdoctors’ abysmal working conditions in the country. Ithad never been clearer that action needed to occur toimprove the situation.

In Taiwan, medicine is considered to be a sacredprofession; seemingly omnipotent doctors are imaginedto have endless devotion, and seen to never get sick, letalone suffer from long work hours. Indeed these beliefs

are even shared by many senior doctors - to them, medi-cine is a responsibility to which they dedicate their wholelives. They think they have the power to escape bodilyweakness in spite of unbelievably long work hours. Butthe facts now come to light.

According to research, the average number of

hours worked per week by residents in Taiwan is about111.87[1], and the maximum shift length is an average of33.5 consecutive hours. This is well beyond the regula-tions proposed by the Accreditation Council for GraduateMedical Education (ACGME) which recommends that

US resident doctors not work over 80 hours a week, andthat the maximum duration of work shifts is kept below16 consecutive hours[2]. Furthermore, statistics show that,after 18 successive hours of work, ICU residents are fivetimes more likely to commit serious medical errors[3]; andthat the mental state of someone who has been awake forthis long resembles that of a person with a blood alcoholconcentration of 0.05%[4]. As we can see, the well-beingof patients is under threat.

Recently, a resident doctor in Taiwan conducteda study focusing on how long work hours can affectresidents both physiologically and mentally[5]. Despitethe significance of the topic, the thesis was turned down

by many well-known medical journals in Europe. Theeditorial boards wrote back, stating they simply could notunderstand how residents could cope with the work hoursstated, thus questioning the reliability of the study.

On May 1st 2011, four days after the intern’s unfortu-nate death, came Labor Day, when workers of all profes-sions marched to defend their rights and to raise aware-ness about unreasonable working conditions. A group ofmedical students, assembled via the Internet, joined themarch to arouse the media and the public’s attention to

the unforeseen consequences of overworked doctors onpatient safety.

Following the demonstration the medical studentscame together again and held their first formal meetingon October 10th 2011. This was the birth of the DoctorWorking Condition Reformation Group (referred to as theReformation Group in the following passages).

The Reformation Group, now comprised of around30 active medical student and resident doctor members,aims at improving the working conditions of doctors. InTaiwan, almost all professions are under the protection of

the Labor Standards Act, which contains regulations onwork hours and compensation of occupational accidents.Doctors are not included on the list, however - allegedlydue to the “unpredictable” nature of medicine.

But doctors’ rights need to be acknowledged, and byno means sacrificed, as they are human beings after all.Through various endeavors, the Reformation Group hasteamed up with FMS-TAIWAN and is trying to put an endto this abuse of human rights. The following approachesthat have been taken are useful for us as medical studentsto think about when it comes to advocacy:

1. Lobby government officials and legislators

For the past two years, Reformation Group membershave attended the public hearings held by Congress.FMS-TAIWAN spoke up there and also hosted severalpress conferences, stating the urgent need for residents tobe included in the Labor Standards Act in order to ensurethe implementation of work hour restrictions. We recom-mended that work hours be reduced to less than 80 hoursa week; that the maximum shift duration not exceed 30hours; and that the frequency of on-call nights not exceedone every three days.

Making a Change through Advocacy

Amy Huai-Shiuan Huang & Heng-Hao Chang

Amy Huai-Shiuan HuangAmy is a second-year medi-cal student at the NationalTaiwan University, Taiwan.Amy may be contacted at:[email protected]

Heng-Hao ChangHeng-Hao is a final-yearmedical student at the

National Taiwan University,Taiwan. He is a formerSecretary General of IFMSAand NMO President of FMS-Taiwan. Heng-Hao may becontacted at: [email protected]

www.ifmsa.org

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The Reformation Group also met with several legisla-tors and officials from the Department of Health to bearwitness with regards to the severity of this issue. In spiteof its long-standing reluctance and procrastination, theDepartment of Health finally admitted the necessity toregulate residents’ duty hours. Promises were made toestablish duty hour regulations in teaching hospitals by

employing a standard contract. The Reformation Groupwas invited to draft this contract pending further negotia-tion. Although the Department of Health has not yet takenexplicit action, we believe this is an optimistic start and wewill continue our efforts to ensure the implementation ofthese new regulations despite the likelihood of objectionfrom hospital administration boards.

2. Raising awareness through campaigns, media andnetworks

We made ourselves seen and heard through the

media. The Reformation Group took part in a number ofmarches - on Labor Day, and on Doctor’s Day - and par-ticipated in the demonstration launched by the NationalLabor Union. The publicity associated with this providedthe opportunity for us to gain broader public support andto get the word out about the predicament residents arefacing. Awareness about the possible threat to patientsafety and healthcare quality began spreading throughthe media’s reports.

In addition, members of FMS-TAIWAN and theReformation Group submitted editorials to noted maga-zines and newspapers, responding to inaccurate doubts

and criticisms. The Reformation Group also formed net-works with organizations from different disciplines, suchas an NGO for patients’ rights as well as the newly estab-lished Nurses’ Union. Furthermore, social networking sitessuch as Facebook were well utilized to promote a moresustainable strategy of health workforce management.

3. Influence Our Peers by Education

Most importantly, medical students themselvesneed to be aware of the problem. In order to educatethem about the seriousness of excessive work hours, the

Reformation Group held numerous lectures in medicalschools around Taiwan, including during FMS-TAIWANevents, where publications about the working conditionsof doctors were issued. Furthermore, the ReformationGroup members met regularly to evaluate their progressand to exchange ideas, keeping themselves abreast withregards to future plans.

There is a saying that when fire is set in a room full of

sleeping people, the few that are sober should try to wakeup as many of the slumbering as possible. If some are leftto sleep on, this is the dead end; but if they are not, a wayout may be found together. The moral of the story is thatthe power of unity can be enormous.

The challenges we face and what we can do in the future

In Taiwanese culture, advocacy has never beenconsidered very important by young people. Medical stu-dents are more absorbed in achieving good grades thanchanging the face of the medical environment they willone day work in. FMS-TAIWAN and the Doctor Working

Condition Reformation Group went against the grain intrying to strike up a revolution. We believe there is no onewho should be more concerned about the problems ofthe healthcare system than healthcare workers themselves.

One big challenge we face is the lack of participationby many residents. It is known that some of them believethe problem will resolve itself with time, however if we canget to know more of their thoughts about the current work-ing conditions, we can better evaluate the situation andthus make improvements in the right direction.

Presently, medical associations are particularly con-cerned that the training of junior doctors may be impairedwith the reduction of duty hours. However previous studieshave shown that reducing working hours to less than 80 aweek has not adversely affected training outcomes in theUS[6]. We understand it is prudent to create supportingpolicies to ensure a better system in which training qualityis not sacrificed, and believe this ideal can be achieved byassigning a rotating group of doctors for overnight shifts;introducing supplementary personnel; and focusing onefficient skill training.

Conclusion

We medical students should recognize advocacyas one of our responsibilities. Medicine is a professionthat has the well-being of billions of people in its hands.After identifying the elements that need to be changed,we need to have the courage and passion to tackle thechallenges. Take the example of work hour reduction, forinstance. This is not just about interns and residents; it isabout each and every one of the people living in Taiwanwho seek medical assistance or who have loved ones un-der medical care. If the situation does not improve, manywill suffer. Our ultimate goal is to create a better systemoverall to improve the quality of healthcare. With a heart,

a will to contribute, a positive belief and continuous effort—let us bring positive change to our medical environment!

1. Yang M.S. , Li Y.F., Wei S.L. An Analysis

of the Work Hours and Related Factors

Associated with Attending Physicians and

Residents in Teaching Hospitals. J Med

Education. 2007; 11(3).

2. Accreditation Council for Graduate

Medical Education. 2011 Duty Hours:

ACGME Standards [Internet]. 2011 [cited

2013 Jan 12]. Available from: http://

www.acgme-2010standards.org/pdf/

monographs/jgme-monograph.pdf

3. Landrigan C, M.D., Rothschild J, M.D.,

Cronin J, M.D., et al. Effect of Reducing

Interns’ Work Hours on Serious Medical

Errors in Intensive Care Units. N Eng J

Med. 2004; 351: 1838-48.

4. Laura K. Barger, Ph.D. et al. ExtendedWork Shifts and the Risk of Motor Vehicle

Crashes among Interns. N Eng J Med.

2005; 352(2): 125-134

5. Lin, Y.H., Kuo, B.J., Ho, Y.c., et al.

Physiological and psychological impacts

on male medical interns during on-call

duty. Stress. January 2012; 15(1): 21–30.

6. Moonesinghe SR, Lowery J, Shahi N,

Millen A, Beard JD. Impact of reduction

in working hours for doctors in training on

postgraduate medical education and pa-

tients’ outcomes: systematic review. BMJ.

2011;342:d1580

References

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Transplant organs. Millions need them, but onlya few lucky thousand get them. Ever since the firstsuccessful organ transplantation in 1905 (cornea),the number of transplantation operations has risensteadily. Demand is ever-present, supply is scarce,and thousands suffer annually as their conditionsdeteriorate while they wait for salvation in the formof a kidney, or a liver, or a heart.

While waiting lists grow, authorities such asthe WHO try to promote transplantation through

programs and slogans such as “If we are preparedto receive a transplant should we need one, thenwe should be ready to give”[1], while hospitals andtransplantation centres flaunt success stories and tryto appeal to the humanitarian aspect. Whether suchefforts are successful or not depends on whom oneasks.

One group may suggest that the rise in successrates is improvement on its own, since it meansthat more and more people are receiving donatedorgans and live out their lives healthy and happy.Others, on the other hand, may stick by the logical

argument that, since potential donors (people withhealthy organs) exceed needy recipients, then thelimiting factor is the rate of actual donations. In otherwords, if every person who dies donates a healthyorgan to a recipient, no one would need to wait fora transplant.

States and healthcare systems try to overcomegaps the best way they can without letting the situ-ation turn into organised organ trade. From simplemotivation to reimbursements, techniques vary be-tween systems. Policy makers try to modify systems

to push the number of donations higher, with vary-ing success, but perhaps behavioural economicscan help.

Behavioural economics is a relatively modernterm, coined to describe the ideas of a historicallyunpopular pattern of thought in Economics, andmade popular thanks to books by Richard Thaler,and Daniel Kahneman, amongst others. Economiststend to assume that humans are rational, consistentbeings who tend to stick to rational systems and toreproduce the same results under the same condi-tions. Psychologists and statisticians often receivecontradicting results, on the other hand.

The effective merge between economics andpsychology has therefore produced the seriesof principles that are behavioural economics.Behavioural economics is said to enhance “the ex-planatory power of economics by providing it withmore realistic psychological foundations” whichwill result in “making better predictions of f ield phe-nomena and suggesting better policy”[2]. This wasrealised when many incongruences in economicsmodels, and their interpretations, were explainedusing psychology. An example is the Status Quo ef-

fect, which explains why most people tend to preferthe “default” option over the more rational ones,contrary to what economic models would havepredicted.

With the rapid emergence of these principles,economists and officials started seeing patterns incertain behaviours that had been previously unex-plained, such as why amateur stock brokers losemore than professional ones, and why this discrep-ancy is not a result of skill on part of the profession-als. Many behavioural economics experts now seethat applying these principles, adding a little psy-

chological understanding into the decisions policymakers make, can go a long way in improving re-sults and achieving targets in most fields. Organtransplantation and the healthcare field in generalcan benefit greatly, they argue, if policy makers paya little more attention to how people normally think.

A common example is presented in RichardThaler’s book, Nudge[3], which refers to an interest-ing piece of statistics: organ donations in Austriavastly exceed those in Germany, even though thosetwo neighbouring countries often show similarities

rather than shocking discrepancies.

Digging deep for the source of the discrepancy,experts have located it in registration papers. InAustria, drivers wishing to opt out of the option ofdonating their organs after a fatal accident had tocheck a box; otherwise they were automaticallyenrolled in the system. In Germany things operatedin the opposite way, with people having to check abox to enrol in a similar program.

This is an application of the previously discussedStatus Quo effect; where people are generallyloathe to change the default options in life. An im-

Behavioural Economics in MedicalPolicy Making: Organ Transplantation

Ismail El-Kharbotly

Ismail El-Kharbotly,

IFMSA-Egypt

www.ifmsa.org

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portant feature in behavioural economics is theeffect norms, social and otherwise, can have onindividuals during the process of decision making.Changing the norm requires active, effortful thinking,and, that being a tiresome and extensively exhaust-ing process at times, leads the human brain to some-times substitute questions.

Instead of asking oneself how many lives couldbe saved using one’s donated organs, one cansometimes end up thinking about the potential loss-es, and how the default option must be so-and-sofor a reason. With that in mind, and with the list ofneedy recipients rising steadily, how can policies bedesigned to help shrink the margin between supplyand demand?

Mandated choice and libertarian paternalismhave been suggested as useful tools. Libertarian

paternalism suggests that, for the state to do every-thing in its might to improve the quality of life for itscitizens, it must seek to minimise the gap betweenorgan supply and demand without forcing choices.Mandated choice, on the other hand, is based onpresumed consent, and is basically the relatively sim-ple task of readjusting policy wording and choicesto help citizens make choices that are better for thestate and other citizens, with the option to opt outavailable and easy.

While many states do not approve of libertarianpaternalism as a concept to go by, many argue that

mandated choice is simply a clever political gimmickgovernments can use to improve statistics and gainpopularity through abuse of the human nature. It isnot unusual for a medical representative, in the pro-cess of extracting an organ from a newly-deceased

donor, to face resistance from family members whodisapprove of the donation. If direct consent is avail-able, it is easy to show family that the deceased hasactively sought to have his organs donated post-mortem, whereas with presumed consent, familymembers may feel cheated out of their rights by thefine-print of documents. It is the role of medical policy

makers to tend to the society as a whole, argues theopposing side, and not just to boost their numbers,and this includes the welfare of the deceased’s fam-ily members who do not need an extra burden tobear shortly after the loss of a loved one.

Judgement is difficult to pass. The use of behav-ioural economics in policy making is a relatively newpractice and may be unheard of to some membersof the public. That said, it probably has a long wayto go in terms of development, integration into so-ciety and gaining public acceptance. The debate

is likely to go on for a long while but it is undeni-able that the use of behavioural sciences has thepotential to revolutionize policy making, especiallyin developing countries, and may actually help savelives, through organ donation, or otherwise.

1. Organisation WH. WHO International

[Internet]. 2012 [cited 2012 December].

Available from: http://www.who.int/

transplantation/donation/en/index.html.

2. Camerer CF, Loewenstein G.

Behavioral Economics: Past, Present,

Future; 2002.

3. Thaler RH, Sunstein CR. Nudge

- Improving Decisions about Health,

Wealth and Happiness. Caravan Books;

2008.

References

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Recently an update of the Cochrane MethodologyReview of Industry Sponsorship and Research Outcome[1] found that “Sponsorship of drug and device studies by themanufacturing company leads to more favorable resultsand conclusions than sponsorship by other sources“. Ibelieve that this observed distortion of outcome by unwisesponsorship is not limited to the realm of clinical trials.

In September 2011, the United Nations declared that,for the first time in human history, chronic non-communica-ble diseases (NCDs) such as heart disease, cancer and

diabetes pose a greater health burden worldwide thando infectious diseases, contributing to 35 million deathsannually. This burden is ever increasing and we need tourgently tackle the primary causes of NCDs. However,there appears to be a number of stumbling blocks on thispath.

The entire WHO budget is only half the budget thatthe Coca-Cola Company spends on marketing, and, inaddition to their marketing influence, industries are usingtheir vast arsenal to get a place at the table of healthpolicy.

Mexico has the second highest rate of obese indi-viduals in the world (falling short to the United States ofAmerica) and is the country with the highest consumptionof Coca- Cola in the world. The Pan American HealthOrganization, a regional office of the WHO - the veryregional office that oversees Mexican public health - ac-cepts money from the Coca- Cola Company, PepsiCo,Kraft, Nestle, and Unilever[2], and some members of theWHO’s Nutrition Guidance Expert Advisory Grouphave food industry ties, receiving funding from Unileverand Nestle[2]. Can a public health agency receive dona-tions from industrial food companies and still be trusted

to create impartial policies and strategies for addressingobesity?

Will this sponsorship help tackle what is undoubtedlythe biggest global health problem we face or is it anotherway to fuel the obesity epidemic by coercing policy mak-ers worldwide? By associating with this event, just like theLondon Olympic Games of 2012, corporations presentthemselves as a part of the solution rather than the prob-lem. The business of industry is to move the responsibilityaway from the company to the individual and make theproblem a consequence of individual decisions ratherthan aggressive marketing or other tactics.

Over the past 50 years, the consumption of sugar hastripled worldwide. Sugar is cheap, desirable, profitableand associated with high blood pressure, heart attacks,obesity, malnutrition and metabolic dysfunction. The for-mer makes it no surprise that industry wants to promoteits use.

I have a British Medical Association position state-ment, “Behaviour change, public health and the role ofthe state”[3] in front of me which states, “Drinks and foodmanufacturers can have significant conflicts of interest

and the state should put the health of citizens before com-mercial freedom”. If we are truly concerned about publichealth, we need to limit the sponsorship and harmful influ-ence of corporations on public health. The World HealthOrganization has noted this, stating “there are areas, suchas public health policy-making and regulatory approval,where the concept of partnership with for-profit enterpriseis not appropriate” [4].

The ultimate goal of industry is profit but also to in-fluence government policy. We, as tomorrow’s doctorshave to take the lead in a public health revolution. Is thissponsorship going to knock us off the path to health equity

for all?

We need to rejuvenate public health; we need toshake things up and take a lead in addressing these is-sues, revitalize its political functions, and regain its role asa champion of those in need.

If we want to make gains and improvements in publichealth, we need to control and limit the commercializationof medicine. Evidence-based legislation is more effectivethan voluntary agreements. If industry wants to contributeto human wellbeing, as it has publicly stated, it should

avoid blocking legislative actions intended to regulate themarketing, advertising and sale of its products

We need to take our knowledge and turn it into ac-tion.

Conflicts of Interest in HealthcareDavid Carroll

David Carroll,

Medsin-UK.David is a medical studentat the Queen’s University ofBelfast; he is currently on thenational committee of Phar-mAware, a MedsinUK activ-ity that aims to promote ethi-cal interactions in healthcare,and Vice-President of theQueen’s University Branch ofMedsinUK. He declares nocompeting interests.

References

1. Lundh A, Sismondo S, Lexchin J, Busuioc OA, Bero L. Industrysponsorship and research out-come. Cochrane Database ofSystematic Reviews 2012, Issue12. Art. No.: MR000033. DOI:10.1002/14651858.MR000033.pub2.2. Reuters. Special Report: Food,beverage industry pays for seatat health-policy table. Availableat http://www.reuters.com/arti-

cle/2012/10/19/us-obesity-who-industry-idUSBRE89I0K620121019.Accessed 9th January 20133. BMA Ethics Department. Behav-iour change, public health and therole of the state. Available onlineat http://bma.org.uk/working-for-change/improving-and-protecting-health/behaviour-change. Accessed9th January 20134. World Health Organization. Pub-lic-Private Partnerships for Health,Trade, foreign policy, diplomacy andhealth. Available at: http://www.who.int/trade/glossary/story077/

en/ Accessed 9th January 2013

www.ifmsa.org

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Health perspectives through the eyes ofa physician-in-training

Franchesca Mirre GonzálezI entered medical school for one

reason: to become the best neurosur-geon and to provide my expertise tothe field of neuroscience research.My world revolved around thisgoal. I thought that medicine wasonly about diagnosing and treatingdiseases. However, through myeducation, I realized that medicineis much more than diseases, innova-tive diagnostics and specialized

treatments, but also a field to pro-mote health and prevent disease.Through educational efforts andhealth collaborations with relevantorganizations, health strategies cancontinue to protect the welfare of thepopulation.

Medical education initiativesinclude regular training of medicalstaff and the population. As physi-cians-in-training, health promotionplays a vital role in the care of ourpatients. We must provide optimal

health services within our medicalinstitutions, educate our patients onimportant health information to moti-vate healthy lifestyle habits, and alsobe advocates for our patients’ healthrights. Often, so busy in learningcountless diseases and their clinicalmanagement, we forget the humanside of medicine, seeing the patientas a “syndrome,” rather than as ahuman being.

Decades ago, physicians were

only concerned about treatment ofthe symptom, not the etiology. Thisphilosophy has modified over time,to highlight the primary mission asdisease prevention. In order to con-tinue to promote this mission, we musttrain and empower future physiciansin every nation to be advocates andfacilitators of health rights and patientsafety.

The World Health Organization(WHO) has designed strategies toencourage community health promo-tion, which is described in the follow-

ing statement: “Health promotion isthe process of enabling people to in-crease control over the determinantsof health and thereby improve theirhealth. Health promotion representsa comprehensive social and politicalprocess; it not only embraces actionsdirected at strengthening the skillsand capabilities of individuals, butalso actions directed towards chang-ing social, environmental and eco-

nomic conditions so as to alleviatetheir impact on public and individualhealth” [1].

In order to design successfulhealth promotion strategies, wemust consider three priorities. Wemust: 1) serve as health advocatesto promote health and diseaseprevention, 2) motivate our patientsto adopt positive lifestyle habits toreach an optimal health status; and3) promote health between society’svarious interests [1].

There have been major changestoward improvement of health sys-tems, although multiple challengesstill remain in patient care and healthservices. Evidence-based strategiesmust be integrated into all hospitalsand schools in order to train futurephysicians on how to improve healthcare services to patients and families.

Nowadays, the physician is nolonger considered the sole protago-nist. Patients must become aware

and take responsibility for theirhealth, understanding their healthrights and information. To ensurepatient education standards are met,it is necessary for the optimal trainingof medical students and residentsas health care advocates to occur.This may be achieved through vari-ous methods, including, promotingnetworking between students andhealth care professionals, designinghealth programs in low resourceareas with poor health care services,and facilitating case discussions on

strategies to improve current globalhealth issues.

The following story by an anony-mous author serves as a reflection forus as physicians-in-training:

Long ago, I heard a little story.The youngest daughter of a peas-ant was brought to the emergencycenter with a high fever. She was di-agnosed with dengue fever, quicklytreated and discharged. Within a

few months, she returned with similarsymptoms, and was diagnosed ashaving a second infection of dengue.After reviewing her medical file, thephysician in charge realized that thisgirl had been admitted twice withinthe year for the same diagnosis.

The physician asked the girl’sfather, “What is the condition of yourhome?”, to which the father replied,“My family lives in a house with alarge yard”. “What do you have inyour yard?” said the physician. The

father replied that he had severalwater storage tanks, in addition to anold car tire.

This was a clue to the causeof the girl’s recurrent illness. Afterthe relationship between stagnantwater, mosquitoes and dengue wasexplained to him, the father realizedthat he should eliminate mosquitobreeding sites in the yard, includingcovering water storage tanks andremoving tires and other containers

that may collect water. He was mo-tivated from this to become a com-munity leader, promoting the healthcampaign to prevent the transmissionof dengue fever.

The act of being a good physi-cian does not only consider the mostaccurate diagnoses and treatments,but rather identifies the disease etiol-ogy and prevents the transmission,progression or complications.

1. World Health Organization.

Health promotion glossary

[Internet]. 1998 [cited 2012 Dec

23]. Available at: http://www.

who.int/healthpromotion/about/

HPR%20Glossary%201998.pdf

Franchesca Mirre González,

IFMSA-Dominican Republic

References

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On June 1st 2012 Bulgaria gave its children a present –a smoke-free environment. This was the day when the partialprohibition was replaced by an absolute prohibition of ciga-rette-smoking in all public areas including sport stadiums, busstops, playgrounds and parks. A huge contribution towardsthis radical change came from the “For Life Without Cigarette-Smoke” Coalition of NGOs, of which the Association ofMedical Students in Bulgaria (AMSB) was one. AMSBrepresented points of view from the Bulgarian youth as wellas from the next generation of physicians.

The coalition was founded approximately two years

ago after it was realized that the law of partial prohibitionwas not meeting the expectations of the people. This law al-lowed smoking in restaurants and cafes provided that areaswere closed off into smoking and non-smoking sections. Barsand nightclubs on the other hand were not even required todivide their premises. This disregarded the rights of customersand staff to a healthy smoke-free leisure and working environ-ment. A large part of the country’s population was beingaffected by cigarette smoke despite the decision by severalmunicipalities and businesses to go smoke-free.

Initially, AMSB started with public discussions aboutwhat we could do to target these practices. We looked forpossible partners, and when we found each other it was time

to act! Our main activities comprised organizing campaigns,health walks, protests and petitions; carrying out surveys; andtaking part in parliamentary debates. We attacked fromevery possible angle using mass media to inform the popula-tion of possible risks and consequences of smoking – bothactive and passive.

After enjoying huge public support we were able to influ-ence the law, amendments of which were voted in favor atthe National Assembly. The result is smoke-free public areasin Bulgaria today.

Much has been done but it is not enough. An acting lawdoes not mean that it is working. In order to work it needs to

be controlled and regulated. For this purpose, mobile publicgroups were founded. They work in collaboration with staterepresentatives such as health inspectors and the police, tovisit different properties (such as restaurants, cafes, nightclubsand schools) and determine whether the law is being ad-hered to or not. Violators are initially warned and then finedafter a second violation. So far 6273 properties in total havebeen inspected and 148 fines have been imposed. A callcentre and website have also been launched so that con-cerned citizens are able to report irregularities.

After enjoying a smoke-free summer and a life span ofjust 4 months the new law was targeted by a number of busi-nesses. They came with statistical data showing financial loss-es during the active summer tourist season, which they stated

was due to the newly enforced prohibition of public smoking.They reported small business bankruptcies, trying to put theirown financial profits over the nation’s health. Those populiststatements were supported by some MPs too. Through themthe cigarette industry was able to propose the restoration ofthe old regulations.

At that moment everything we had done so far seemedendangered. All efforts we had made up to that momentseemed meaningless. The dilemma was how we were goingto face the situation.

The new regulations enjoyed huge popularity amongst

the people of Bulgaria but there were also many againstthem. This was the moment when we had to decide whetherto step back or keep defending the law. After extensive talksand negotiations we decided to keep to our previous state-ment: that smoking should be banned in all public premisesin order to ensure a healthy living environment to our nation-als, foreign guests and most importantly – to the children ofBulgaria. We continued insisting on improving public healthto be among the major state policies.

The debates over the new proposals made by business-es were aired on TV shows, radio programs and featuredin newsletter articles. All possible kinds of mass media wereused to allow citizens to take a position and express their

opinion. We, as medical students, kept to the health-relatedaspects of the problem. We presented scientific evidence oflinks between smoking and lung and other types of cancer,talked about the effects of passive smoking, discussed the costof treatment of smoking-related diseases, and revealed thesuccessful examples of other smoke-free countries.

After a round of public debates (in which medicalstudents from AMSB took part) came the moment of truth– discussions in the Parliamentary Commission of Health, fol-lowing which was the voting procedure by MPs. Ultimatelywe succeeded in convincing MPs of the benefits of the act-ing law. And with 11 out of 11 votes in the commission the

amendments to the law were not approved.Our second victory was a fact: using the right advocacy

techniques at the right time led us to success once again. Andwe, as medical students, have our own contributions to thankfor this success. We have shown the public that the voice ofthe youth is a power no-one can defeat; that youths’ ideas aresupported by facts; that our objectives and aims are achiev-able and sustainable; and that we will not stop doing ourbest to increase the health status of the people. As the nextgeneration of physicians, we gave our share for a healthierfuture Bulgarian population. And we will do it again andagain until we reach our ultimate goal – the highest possiblelevel of health for all people.

Praise your health: For life withouttobacco smoke

Byurhan Rashid

Byurhan Rashid,Medical University of Sofia,AMSB-Bulgaria

www.ifmsa.org

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Physician advocacy: obligations vsaspiration

Jihad Abdelgadir Imam

Most, if not all, physicians arewell acquainted with their roles asadvocates for the individual patient.Physicians consider advocacy for anindividual an accepted componentof ethical practice, yet this alonedoes not meet the requirement for“public advocacy on the part ofeach physician.” Advocacy, ac-cording to this broader perspective,requires more than helping individual

patients get the services they need; itrequires working to address the rootcauses of the problems they face.Nevertheless, all physicians’ obliga-tions to advocacy are grounded intheir professional experience and ex-pertise and their duty to their patients.Each physician’s obligation to advo-cacy must take into consideration thelimits of his or her expertise.

The American MedicalAssociation’s definition of physician

advocacy is “Action by a physicianto promote those social, economic,educational, and political changesthat ameliorate the suffering andthreats to human health and well-be-ing that he or she identifies throughhis or her professional work andexpertise” [1].

Increasingly, medical profession-als are engaging in community andhealth policy arenas [2,3]. This involve-

ment is a response to a heightenedawareness that many health issueshave their roots in the community.Aspects of modern culture that giverise to diseases, such as environmen-tal contamination, represent the newvectors of disease[4]. To address themone must practice both inside andoutside of the clinic walls, and phy-sician advocacy is one approach.One definition from the Lancet states“Advocacy only means taking theproblems that one faces day to dayand pursuing their resolution outside

their usual place of presentation” [5].Physicians actually have a dual

role, I believe, as patient caregiversand managers of healthcare re-sources. According to a report fromthe Council on Ethical and JudicialAffairs, a physician’s “primaryethical obligation is to promote thewell-being of individual patients”[9].However the report acknowledgedthat “physicians also have long-rec-

ognized responsibilities to patientsin general, to promote public healthand access to care for all patients”[9] -responsibilities that require physiciansto be prudent stewards of sharedhealthcare resources. But it is hardto balance between the two, whichis why it is hard for the physicianto advocate. Ultimately physiciansshould find a way to balance their re-sponsibility to care for a patient whilepreserving the healthcare resourcesfor others.

Physicians have an obligation towork within their own practices andcommunities to ensure that patientshave access to high-quality preven-tive, urgent, and specialty care thatis geographically, linguistically, cul-turally, and financially accessible[6].These noble ambitions frequentlycounteract with the financial realitiesof a growing uninsured and un-derinsured population[7]. Practicing

physicians are caught in the debatebetween the utilitarian idea of dis-tributive justice, which acknowledgesfinite resources, and the idea of jus-tice as equity where all patients areguaranteed equitable access. This isa crucial debate, and one in whichdoctors must be heard.

The strength of the link betweena policy and a health outcome canguide physicians in distinguishingtheir obligations from their aspira-tions when advocating for patients[6].

For instance, Gruen et al suggest thatit is the physician’s obligation to workwith individual patients and in thelarger realm to reduce tobacco usebecause the health implications of to-bacco use are well established. Theyalso suggest that physicians mayaspire to address factors such aspoor educational opportunities andneighbourhood safety, for which theimpact on health outcomes is sug-

gestive but not conclusive. Hence,determining the strength of thescientific evidence can help a physi-cian prioritize his obligations over hisaspirations[6].

We cannot expect, nor shouldwe, that doctors of this world willbecome individual crusaders, spend-ing 20 hours per week trying to helpsolve the health problems brought onby persistent poverty, substandardliving- and nutritional-conditions, a

lack of healthcare insurance cover-age, and inadequate access to care.It is unrealistic, given how demand-ing and personally-testing the life ofthe average doctor is nowadays.

What we should expect, andwhat doctors are obligated to do,is to engage in professional organi-zations actively to serve as agentsof change, working to correct theadverse conditions in which many

people toil and which contribute topoor health [8].

No epidemic has ever beenhalted by focusing on the individualpatient, and many of the health is-sues facing our nation and worldtoday pose similar challenges. Asphysicians learn to advocate for bothindividuals as well as communities,they will improve the lives of manywhile they enhance the quality andenjoyment of their work. Successfuladvocacy is achievable with both a

1. American Medical Association.

Declaration of Professional Responsibility:

Medicine’s Social Contract with

Humanity. Mo Med. 2002 May;

99(5):195.

2. Chamberlain LJ, Sanders LM,

Takayama JI. Child advocacy training:

curriculum outcomes and resident satisfac-

tion. Arch Pediatr Adolesc Med. 2005;

159:842-847.

3. ABIM Foundation, American Board

of Internal Medicine; ACP-ASIM

Foundation, American College of

Physicians-American Society of Internal

Medicine; European Federation of

Internal Medicine. Medical profes-

sionalism in the new millennium: a

physician charter. Ann Intern Med. 2002;

136:243-246.

4. Syme SL. Social determinants of health:

the community as an empowered partner.

Prev Chronic Dis. 2004; 1:A02.

5. Horton R. The doctor’s role in advo-

cacy. Lancet. 2002; 359:458.6. Gruen RL, Pearson SD, Brennan TA.

Physician-citizens—public roles and

professional obligations. JAMA. 2004;

291:94-98.

7. Rivara FP. Sustaining optimism. Arch

Pediatr Adolesc Med. 2004; 158:414-

415.

8. Hoff T. The physician as worker: what

it means and why now? Health Care

Manage Rev. 2001; 26:53-70.

9. Douglas SP. Report of the Council on

Ethical and Judicial Affairs. Council on

Ethical and Judicial Affairs; 2012

References:

clearer understanding of its com-ponents and deliberate practicefrom committed physicians.

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The role I most identify with today is that of a student.A learner. I know that is mostly due to my role as a clini-cal clerk, or third year medical student, currently learn-ing how to survive day to day in the hospital and on theward. Thus, when I reflect about the term Advocacy, Ibelieve that today I remain a student, learning what thatword means to me as an individual and as a future medi-cal practitioner. To me, Advocacy inspires me to get outthere and learn, because if I don’t understand the causeof what I am advocating for, then what’s the point?

Since that fateful day when I read the words“Congratulations, you have been accepted…”, I haveconsidered my medical education to be my ticket intothe world of international development. With the tools Iwill obtain through my medical degree, I dream of set-ting up medical clinics in remote jungles and respondingto need following natural disasters.

Prior to medical school, I volunteered at a ruralSalvation Army medical clinic in Ghana, where I wasthe lone obruni, or white person, in a four-hour radius.During an outreach trip after my first year of medicalschool, I traveled to the Thailand-Cambodia border to

assist a team setting up primary care clinics for displacedpeople. Although I thoroughly enjoyed traveling acrossthe globe, as it was deeply satisfying and inspiring, arecent experience showed me the great need for healthcare development close to home, in my own province ofBritish Columbia.

This summer, after finishing my pre-clerkship years inVancouver at the southern end of the province, I travelednorth to complete my rural rotation in northern BritishColumbia. Throughout my rotation, it became increas-ingly evident that the aboriginal First Nations communi-

ties in northern Canada face a unique set of struggles.As a member of the University of British Columbia’sAboriginal Health Initiative group, I made it a personalpriority to serve and learn about these populations dur-ing my time in the north. When an opportunity arose totravel to four of the First Nations communities over thecourse of a week, I was quick to volunteer.

Monday took us to a small First Nations reserve of220 people which has been established for hundreds ofyears but still lacks basic access to medical care. After asix-hour drive through the mountains on a dusty loggingroad, we arrived at the edge of Takla Lake at a reserveof 250 residents, an astounding 320 kilometers from

the closest medical center. Every day, my eyes wereopened to the enormous challenges of the aboriginalresidents of these reserves. The inability to overcomelanguage, financial and education barriers has resultedin a complete lack of medical care for these communi-ties. Children presented for check-ups with lice crawlingdown from their hairlines. Bugs were fished from earcanals. Countless referrals were made to larger medicalcenters for incontinence, visual impairment and dentalmaladies.

We concluded the week by helicoptering two hourswestward to work for a day at two other small communi-ties on Lake Babine. Our days were physically taxingyet emotionally satisfying. As we traveled through thelush green mountains of Northern BC, the poverty andremoteness of the communities was striking. I found ithard to believe that in my native BC, individuals live insuch isolation and travel such long distances to obtainbasic medical care.

In one community, we met a woman in her 30thweek of pregnancy who had not yet received anyprenatal care. As we attempted to connect her with the

local nurse practitioner and provide her with the ap-propriate swabs, screens and exams, it was humbling tothink about how her physical remoteness had translatedinto her hesitation to seek care. In another community,we met two elders who struggled with constant dyspneadue to long term COPD. Although they desperatelyneeded at-home oxygen, they had no voice to advo-cate for them, and their breathlessness remained. Theevidence of substance dependence and the wake ofcolonization touched nearly everyone we saw.

This week-long trip not only enriched my experience

during my rural rotation, but it also has broadened myperspective and understanding of family medicine andrural medical practice. I am thankful for the Takla Lake,Tl’azt’en and Lake Babine Nations for welcoming us andteaching our team so much. I would strongly encourageany students or residents who express an interest in FirstNations health or international development to seek anexperience like this one.

It is now fully evident to me that my medical skillscan, indeed, provide me with powerful tools to advo-cate for my patients within the realm of internationaldevelopment. However, I may not have to travel as faras I once believed.

Discovering Purpose for Advocacy inmy own Neighborhood

Tara Dawn

By Tara Dawn,

CFMS-Canada

www.ifmsa.org

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Development of physician health careadvocates through leadership training in

social determinants of healthHelena Chapman

In modern medicine, the Hippocratic Oath symbol-izes the formal obligation of physicians to the care of theirpatients, professionalism and social and ethical responsi-bilities[1]. Physicians serve as health care advocates, or“navigators”, for their patients, guiding them through avariety of health services to promote health and preventdisease. However, within the past decade, the social andphysical factors that describe how individuals age, live,work and spend leisure (called the social determinants ofhealth) have been highlighted as a link to health inequali-ties (Figure 1)[2, 3].

As a result, physicians should not only acknowledgethe pathophysiological mechanisms of disease, but alsounderstand the current global health disease distributions,

identify modifiable social risk factors and recognize theshift toward preventive medicine[2]. As such, and sincephysicians remain leaders and team members in thehealth care setting, their medical education and clinicaltraining should highlight health promotion and diseaseprevention, team-based learning and other professionaldevelopment skills[4].

Although the traditional medical model focuses on

the diagnosis and treatment of pathological conditions,the new emphasis on incorporating principles of publicand global health requires future physicians to reflect on

the social determinants of health that impact the medicalmodel when considering treatment options. Unequalavailability of resources and inadequate access to healthcare services and technologies continue to complicate ef-forts for disease prevention and management[5, 6].

For example, in some low-income communities, fewgrocery stores sell fresh fruit and vegetables, and trans-portation services are costly and limited. Thus, citizensin those communities must rely on fast foods with high-fatcontent for their meals. Physicians who do not understandthe impact of social determinants of health would beineffective when prescribing treatment plans that empha-size low-fat meals and weight reduction to patients with

cardiovascular disease risk factors. These health carechallenges reflect the need for more emphasis on patienthealth advocacy with an understanding of social deter-minants of health for optimal outcomes. These principlesneed to be applied in the development of health policiesfor the population[4].

The question remains: How can future physicians de-velop personal and professional skills in health advocacyfor patients? Although the answer may appear simple,we should consider a three-step approach that offers

insight on how the physician-in-training learns and actsto implement health care advocacy in his or her futurecareer:

1. Vision: Leadership skills at workWarren G. Bennis once said that “Leadership is the

capacity to translate vision into reality.” The implemen-tation of educational seminars into the current medicaleducation system would promote, inside the traditionalclassroom setting, an open dialogue about health advo-cacy topics, such as, factors that may affect the availabilityof, and access to, health care services; and changes inhealth policy [5].

Since many factors can influence health status, acomprehensive discussion should consider the impact ofsocial determinants of health on an individual, family orcommunity; especially where or how people live, attitudesand perceptions on behaviors or health status, availablechoices, and policies that might be implemented to re-duce health disparities [2, 6]. Using such an approach inthe classroom, physicians-in-training would have exposureto health advocacy terminology and case studies on eth-ics and professionalism in the medical field [2].

2. Empathy: Value of leadership and learningFormer US President John F. Kennedy once said that

“Leadership and learning are indispensable to eachother.” The medical education program should contain aformal training period in clinical and fieldwork settings sothat the physician-in-training understands the importanceof health advocacy and identifies factors that may serveas barriers in patient care. To interact with patients in theclinical setting, and later compare these experiences withthose in impoverished community settings, the physician-in-training can gain insight to the critical role of socialdeterminants of health and available health technologiesin practice [5].

1. Smith DC. The Hippocratic Oath and

modern medicine. J Hist Med Allied Sci

1996;51(4):484-500.

2. Chokshi DA. Teaching about health

disparities using a social determinants

framework. J Gen Intern Med

2010;25(Suppl 2):182-185.

3. U.S. Department of Health and

Human Services. Healthy People 2020:

Social determinants of health. 2012.

Available at: http://www.healthypeople.

gov/2020/topicsobjectives2020/overview.aspx?topicid=39

4. Croft D, Jay SJ, Meslin EM, Gaffney

MM, Odell JD. Perspective: Is it time for

advocacy training in medical education?

Acad Med 2012;87(9):1165-1170.

5. Howitt P et al. Technologies for global

health. Lancet 2012;380(9840):507-

535.

6. Braveman PA, Egerter SA,

Mockenhaupt RE. Broadening the

focus: The need to address the social

determinants of health. Am J Prev Med

2011;40(1S1):S4-S18.

References

Helena Chapman,IFMSA-Dominican Republic(ODEM).

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For example, the home environment may have out-door plumbing or an open woodstove for cooking. Theseconditions may result in health problems relating to thegastrointestinal and respiratory systems, respectively, forall inhabitants of the home [5]. Demonstrating knowledgeof these environmental conditions during fieldwork expe-riences, the physician-in-training may gain insight on the

complex scenario where social determinants of healthmay serve as barriers to maintaining optimal health sta-tus. Learning in the community setting is a critical tool tocomplement classroom knowledge on health advocacytoward better health care services for patients.

3. Action: Leadership as an empowerment tool

Former US President John Quincy Adams once said,“If your actions inspire others to dream more, learn more,do more and become more, you are a leader.” Futurephysicians are not only role models for their patients,

but also serve as mentors for other physicians-in-training.Empowering future physicians to acquire knowledge andskills about health advocacy with an understanding of so-cial determinants of health can motivate them to turn theirleadership skills into professional and responsible actionsfor patient advocacy and care[4]. Even more immersedin health advocacy topics, physicians may participateactively in health policy decision-making within their hos-pital, clinical specialty and professional medical societies,which in turn can facilitate a dialogue between leaders

to improve patient care and reduce health inequalities [4].

In order to fully comprehend the roles and respon-sibilities of physicians as they “navigate” their patientsthrough health care services, physicians-in-training shouldhave early exposure to professional development course-work, including health advocacy, ethics, complex clinical

scenarios and social determinants of health in clinicaland community settings. Once this exposure has takenplace, and, as physicians guiding their patients throughpreventive and curative health services, they will be moreeffective in not only mitigating the effects of disease, butalso incorporating the preventive health principles in theirpractice [2].

Since the literature has confirmed the associationbetween poor health status in childhood and subsequentpoor health status in adulthood, it is of even greater im-portance to identify any barriers to health care services in

combatting this global health issue[6]

. Since physicians-in-training have a critical role in the management of patienthealth care services, any barriers to positive health out-comes should be identified and managed as needed [6].After all, the Hippocratic Oath remains a symbol of boththe vocation as well as the responsibilities of physiciansthat are visualized through moral and ethical actions, andsocial responsibilities [1].

Let us be BoldGithui Sheila Wanjiku & Ndemange Mutuku

Githui Sheila Wanjiku &Ndemange MutukuMedical Students’ Associa-

tion of Kenya (MSAKE).

I wake up one morning and, while doing my social media

rounds, blue is suddenly everywhere - more blue is showing up

on Facebook than just the usual logo and header. Curious, I

decide to inquire more on the “Blue Revolution”, code-named

Linda Afya (Protect Health). My interest goes little beyond this

initial curiosity. All I learn from my inquiry is that a doctors’ strike

is looming. I shelve the whole idea. I am, after all, a second-year

medical student with a busy schedule and end-of-year exams

coming up. I have barely seen the inside of a ward. So I goon with my busy-ness, liking the Facebook page as a sign of

solidarity.

The strike begins on December 5th, 2010. We have

already been on our holidays for a while. Even so, I am not

bothered to participate in the planned street demonstrations -

which have now become the only way to get a point across to

the Kenyan government. I, however, follow the events closely on

social media.

A day into the strike, medical services in all public health

facilities are paralysed, and the common mwananchi - the citi-

zenry - is squarely bearing the brunt of a war that should never

have been. The strike is now all over the news. No broadcast is

complete without its mention. A nation’s eyes, perhaps for the first

time in decades, are turned to the plight of a health sector that

has barely been keeping its people alive. Gruesome images

paint the television screens. And then the inevitable happens.

There is a death, and then a second. The doctors stand their

ground. The government will not do so much as comment on

the whole matter.

For a moment, it appears that this drizzle is bound to be-

come a driving rain. And then one Sunday afternoon, there are

rumours of a hurriedly organised meeting. That evening, just intime for the prime-time news, the strike is called off at a press con-

ference. A deal is reached. Timelines are given and promises

made. And the nation’s doctors return to work.

As a human being, I was deeply saddened by the loss of

lives simply because the government would not come to the

table and listen to the doctors - even with a sufficient strike notice

having been issued. I felt that people had died on our watch -

people who could not afford the costly private healthcare that

the men and women in power enjoyed. The media could not

allow themselves to see beyond the request made for better

remuneration; they kept telling the public it was all about money

and presented doctors as a greedy lot.

A little more salary is definitely nice. But surgical gloves are

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far better, as is better diagnostic equipment - but nothing

too fancy. Even one more CT scan and MRI machine

will go a long way. A second radiotherapy machine

would also be nice for our population of 40 million,

and more so because we are faced with a growing

cancer epidemic. Essential medicines, more doctors,

more health facilities, a bigger budgetary allocation to

health (not a paltry 6%) - all these things are definitelynice. Linda Afya was about more than the money.

In January 2012, a taskforce appointed to look

into the issues raised by Linda Afya presented its report,

the Musyimi Taskforce Report. It was just what the doc-

tor ordered.

It was barely four months into the year 2012 when

Linda Afya 2 came along. It was April, and the medical

students who had graduated in 2011 were meant to

have been posted as interns to various hospitals. For

some reason, government was delaying their posting.

This time I was more aware of the issues at stake

- how the delay would affect healthcare delivery, aswell as my future. I would not be left behind or on the

sidelines. And so we took to the streets to demand that

trained doctors, which the country barely had enough

of, be posted to their stations of duty. Linda Afya 2 was

a resounding success.

History, Karl Marx commented, repeats itself - first

as tragedy, second as farce. In September 2012, doc-

tors in Kenya downed their tools once more, this time to

protest an issue whose solutions were clearly outlined in

the January 2012 Musyimi Taskforce Report.

Registrars are the Kenyan equivalent of a resident,

and except for a small fraction on government sponsor-

ship, they receive no remuneration for any of the servic-

es they offer at the two national referral hospitals where

they are trained. Brilliance and fortitude notwithstand-

ing, none of these exceptional self-sponsored registrars

is solar-powered. They need sustenance for themselves

and their families, as well as money to pay their fees,

and considering their schedules and the workload, no

possible amount of moonlighting will suffice to cater for

all these needs.

Still, government had refused to pay them. Once

more, we took to the streets and to social media. This

time though, we took to the streets as a single, solid

front. None of the older generations of doctors lookeddown at the younger ones who drove the protests as

youthful and unwise, and more of the students joined

the effort. We had never been so successful in galvanis-

ing public opinion to our favour as a fraternity. This time,

Kenyans from every walk of life became familiar with

the plight of healthcare in Kenya.

In a speech, the Minister of Medical Services

called the doctors spoilt children crying for peremende

(candy). In the week that followed, the Peremende

Movement was born: never before had information on

the state of health been disseminated more creatively

and effectively. Coverage of the Movement went be-

yond local media to the Cable News Network. The

government would eventually cede ground and set

aside some money for the registrars.

Forty-nine years ago the Union Jack came down

and the flag of the Republic of Kenya flew for the

first time. Mzee Jomo Kenyatta, the founding father

of the Nation, declared war on ujinga (ignorance),

umaskini (poverty), and ugonjwa (disease). Countless

similar declarations were made all over the continent asindependence was attained by different African coun-

tries. But now, years later, a majority of African health

systems fail to deliver an acceptable standard of care.

For the most part, this is not because those in power are

short of guidelines on how to reform health sectors and

deliver the highest attainable quality of care. Rather, it

would seem that healthcare is not a priority for most of

our governments.

We have attempted to recount the experience of

Kenyan health care practitioners and trainees in making

health a priority. We will now attempt to draw lessons

from it that may be replicated here or elsewhere.The Constitution of Kenya begins (as do many

democratic constitutions all over the world) by stating

that all sovereign power belongs to the people of

Kenya. This power is then delegated to various State

organs. It can therefore be safely assumed that State or-

gans, if they wish to survive, must do the bidding of the

people. In such a case then, rather than persuade our

governments to make health a priority, it is the people

that must be persuaded.

In the experience we have described, it will be

noticed that as the issues at play were thrust further and

further into public prominence, the State became more

and more acquiescent to the demands of healthcare

practitioners and trainees. It must therefore become a

priority for those who would reform healthcare to edu-

cate the public on what their rights are, and what the

current state of delivery on those rights is. In the matter

of health, ignorance is the highest vulnerability, and

information the greatest defence.

A public that is fully aware of their right to the

highest attainable standard of health will not only

defend that right, but demand it where it is not given.

Such demands and defences will extend beyond the

public arena to the privacy of the ballot, and change

will begin.The challenge then becomes how to inform the

public - the messenger and the means.

In the Kenyan experience, the message was borne

primarily by health practitioners, who, inasmuch as they

were effective, were effective at a cost to healthcare

delivery, having to abandon work numerous times.

Medical students were, in a majority of cases, very slow

to take up arms. But those who did did so brilliantly, pro-

viding crucial numbers for the demonstrations as well as

for maintaining debate on the issues online.

Unfortunately, there were many who, beyond put-

ting up an appearance of solidarity, did little to support

the cause. These cannot be faulted. We have been

raised in a culture where apathy is almost encouraged.

We have been taught to be content with our comforts

and to keep mum and not make trouble. But medical

training in Kenya exposes one to a world about which

one cannot keep silent. One’s knowledge of suffering

becomes all too real. We have no doubt countless such

medical students exist worldwide. It is these we must

lend a voice to if the physician-in-training is to contributemeaningfully to the fight for justice in healthcare deliv-

ery for all. As it is, our ranks are thin. The ranks of those

who go before us are even thinner. In Kenya there are

barely 3000 doctors in the public service catering for

a large fraction of the 40 million citizens. The number

of medical students hovers about the same figure. But

many stand by and watch as the struggle unfolds.

These must be converted to the cause. Our ranks must

swell. All hands that can be, must be on deck.

Regarding means: social media and demonstra-

tions were the primary means by which Linda Afya and

the Peremende Movement reached out to the public.In time, the debate moved to mainstream media. The

debate here was however brief, and often times more

likely to misinform than tackle the issues at play. While

we encourage that conversations be maintained on

social media, it is important to note the limited reach,

especially in a setting like the Kenyan one. It does have

the advantage of reaching the more urban audience,

who can then be informed to carry the message further.

But then there are countless rural folk who have as

much right to health as the urban folk. Discussion on the

right to health must therefore go beyond social media

into radio, print, television and real-life conversation.

However it is that people are engaged, they must be

reminded of this right, as of their other rights. Our means

must be as diverse and informative as possible. But we

must always remember to retain the purity of our story

and present it in its entirety, not permitting distortions.

While our conversations are to be primarily with

the people, let it not be forgotten that truth must still be

spoken to power. The health care practitioners and the

trainees must be at the forefront in reminding our gov-

ernments that we have not forgotten the commitments

and promises they have made regarding health. And if

we have first spoken to the people, they will stand with

us, and those in power will know that they must deliver -because it is not their power, but the peoples’.

Our minds will tell us that this is all very utopian.

But we only say it because we have seen it and seen

how much more can be achieved. But this achievement

lies beyond a threshold that will take boldness to cross.

A threshold beyond which there is neither romantic

adventure nor ideological steed to mount and wage

war with. Beyond that threshold there is only blood, toil,

tears and sweat. Friends, we cannot imagine a better

world and then stand by and let that dream die. Let us

therefore be Bold.

{ Advocacy }



18/100

MDGs and HIV/AIDS Control

It has now been more than a decade since mem-ber states of the United Nations signed the MillenniumDeclaration, promising a bold vision to rid the world ofextreme poverty, hunger, illiteracy, and gain controlover infectious diseases by 2015. According to the2011 Millennium Development Goals Report, HIV/AIDS incidence rates declined by 25 percent between2001 to 2009 worldwide[1]. And by 2009, 5.25 mil-lion people were receiving treatment in low and mid-

dle-income countries—an increase of over 1.2 millionpeople since 20081. The Millennium DevelopmentGoals (MDGs) have shaped global and nationalpriorities. Despite this progress, we are yet to conquergross health disparities in HIV/AIDS care, part of theproblem being inadequate action on the social deter-minants of HIV/AIDS.

What are the Social Determinants of Health?

The World Health Organization defines the socialdeterminants of health as “conditions in which peopleare born, grow, live, work and age, including the

health system. These circumstances are shaped by thedistribution of money, power and resources at global,national and local levels, which are themselves influ-enced by policy choices. The social determinants ofhealth are mostly responsible for health inequities - theunfair and avoidable differences in health status seenwithin and between countries.”[2].

Public and global health modalities demonstratethat conditions in which a person lives, grows, works,and ages greatly influence the way she is exposedto certain disease risk factors and shape behaviors

and daily activities that can lead to lifestyle diseases.Therefore, the issue of social determinants is especiallyaugmented in the case of marginalized groups (such aspeople living with HIV/AIDS (PLWHA)), wherein suchgroups are disproportionately affected as comparedto the rest of the population. This calls for specializedpolicies to address determinants unique to PLWHAsuch as harm reduction practices, addressing culturaland societal stigma, ethnic and immigrant populationdisparities, women’s status, and homophobia, to namea few.

Human Rights, MDGs and HIV/AIDS: Where do westand?

The MDGs outline a focused strategy on HIV/AIDScontrol in several realms. Target 6A: “Have halted by2015 and begun to reverse the spread of HIV/AIDS”,acknowledges that HIV knowledge and prevention isproportional to wealth and urban population in sub-Saharan Africa, and calls for taking gender-specificconcerns into account. Target 6B: “Achieve, by 2010,universal access to treatment for HIV/AIDS for all thosewho need it”, highlights the need for affordable, acces-sible and universal access to HIV/AIDS treatment[3].

But the human rights issue of HIV/AIDS health dis-parities is still profound. HIV/AIDS care of ethnic andimmigrant minorities, for instance, is a key human rightsissue. By 2007, ethnic minorities in the U.S. comprisednearly 35 percent of the population[4]. Analysis of datafrom the HIV Cost and Services Utilization Study [5] revealed that, compared with non-minorities, womenand African Americans with HIV who were receivingcare were less likely to receive antiretroviral therapy.Overall, the public ranks HIV/AIDS second, behindcancer, as the most urgent health problem facing theU.S.; but amongst African Americans HIV/AIDS ranks

first. After several years of decline in urgency, it hasincreased somewhat since 2002 [6].

That said, simultaneous action on the social deter-minants of HIV/AIDS - which will inherently also ad-dress human rights issues - is critical to achieving MDGGoal #6. The MDGs pledge to ensure health accessand affordable care for all, and also recognize thatsocial determinants play a key role in our fight againstHIV/AIDS. Despite this, a focused and active humanrights approach is lacking. To turn the tide together onHIV/AIDS, it is imperative that we adopt synergism in

our action on social determinants and human rightsissues unique to HIV/AIDS to promote health equity.

Why the Social Determinants of HIV/AIDS are aHuman Rights Issue

These social determinants of health bring aboutinequities in health, which are defined as “inequalitiesin health that are deemed to be unfair or stemmingfrom some form of injustice”. In 1978, the Alma AtaDeclaration reaffirmed the concept of health as abasic human right, recognizing gross inequalities in

The Millennium Development Goals &Human Rights in HIV/AIDSTurning the Tide through Synergistic Action on its Social Determinants & Human Rights

Nilofer Khan Habibullah

Nilofer Khan Habibullah,

AMSA-USA.Nilofer is a fourth-year medi-cal student at the AmericanInternational Medical Uni-versity in St. Lucia, the WestIndies.

www.ifmsa.org

{ MSI27 }

18


19/100

health status between people as politically, sociallyand economically unacceptable. HIV/AIDS, therefore,has a direct relationship to these social determinants ofhealth, and variables which dictate the human rightsdynamics of this issue.

To explicitly highlight this relationship, it’s pivotal

to mention the well-documented fact that prevalenceof HIV/AIDS is rampant in lower socio-economic andculturally marginalized groups. Marginalized sub-groups within the HIV/AIDS population, such as menwho have sex with men (MSM), and sex workers etc,are less likely to have access to quality and affordablehealthcare. These subgroups face ostracism from alllevels, and, therefore, are often denied rights enshrinedin the Universal Declaration of Human Rights. When hu-man rights, which encompass civil, political, economic,social and cultural rights, are protected and preserved,we are able to proactively contribute to ameliorating

HIV/AIDS, infection rates decline, and PLWHA andtheir communities can better cope with the disease.

In addition, several international instruments, suchas the International Guidelines on HIV/AIDS andHuman Rights, and the Declaration of Commitmenton HIV/AIDS, adopted at the UN General AssemblySpecial Session on HIV/AIDS in 2001, mention that allpeople, rich and poor, without distinction of age, gen-der or race are affected by the HIV/AIDS epidemic,further noting that people in developing countries arethe most affected and that women, young adults andchildren, in particular girls, are the most vulnerable.

Furthermore, these international instruments recognizethat the continuing spread of HIV/AIDS will constitutea serious obstacle to the realization of the global de-velopment goals adopted at the Millennium Summit.These instruments also understand that the full realiza-tion of human rights and fundamental freedoms for allis integral to carrying out an effective global responseto the HIV/AIDS pandemic in the areas of prevention,care, support and treatment, and that ensuring them re-duces vulnerability to HIV/AIDS, and prevents stigmaand discrimination of PLWHA [7, 8].

Human Rights, MDGs and HIV/AIDS: AdvocacyDomains to Pursue

To ensure adequate protection of human rightsin HIV/AIDS care, it is critical to ensure synergism ina

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