#endpolio

There is nothing in medicine more elegant than a public health strategy, especially one that is well-planned and conducted efficiently. One of the best examples of such a strategy can be found in the Global Polio Eradication Strategy. The hope is that such a strategy will do for the world what a similar strategy did for Canada.
In 1953, polio peaked in Canada and, in a one year period, there were 9,000 new cases and approximately 500 deaths. The Salk vaccine was introduced in 1955 and the Sabin oral vaccine in 1962 and within 20 years of the 1953 peak, polio was under control in Canada. In 1994, Canada was declared “polio free”. In its peak years, the disease was so widespread that everyone knew a child who had developed limb paralysis because of polio. Of those who developed paralysis, 5-10% could develop paralysis of the respiratory muscles which could result in their death. It was for these people that the iron lung was developed.
Polio was a major worry for Canadian parents in the 1950’s. For many children, polio would cause fever, fatigue, vomiting, neck stiffness, headache and limb pain. I had two aunts who were pediatric nurses and I remember them speaking about the helplessness they felt nursing a child who had seemed to have a mild illness and then suddenly began to develop paralysis. My aunts have spoken about how much parents would dread whenever their child developed a fever.
When the Global Polio Eradication Strategy was initiated in 1988, there were still 350,000 cases of polio worldwide. The strategy was launched in response to a Resolution passed at the World Health Assembly. Within 20 years, thanks to 3 million volunteers worldwide, there has been so much progress toward eradicating polio that the World Health Organization believes it might be possible to eradicate polio by 2018.
The last bastion for polio is in three countries: Nigeria, Afghanistan and Pakistan. The challenges that perpetuate polio in these countries include insecurity, weak health systems and poor sanitation. It is possible for polio to migrate from these countries to other countries whose health systems are weakened by the same factors. For example, cases of polio are now being tracked in Syria.
The public health professionals and advocates involved in the efforts to eradicate polio are determined and diligent, and they will succeed. From the offices of the World Health Organization in Geneva to the grassroots volunteers around the world, there is a hopefulness in their websites and statements that is undeniable. What must be done to achieve their goal is simple: every child must be vaccinated against polio. It takes a lot of work to ensure that this is happening but many countries, and not just countries as rich as Canada, are managing this.
It is easy to understand why this can be managed. Anyone who has witnessed the suffering of a child with polio will want to prevent it. These witnesses will work to ensure that every child can be vaccinated. It is simple and elegant. You can watch the progress on social media by watching #endpolio. You can watch public health at work. You can watch the end of polio.
(Credit: This image of an iron lung is taken from the website of the Canadian Public Health Agency.)

One Hundred Years of Women Doctors

Over the next ten years, various women’s medical organizations from around the world will be celebrating their centenaries. I was contemplating this while attending the Centenary of Britain’s Medical Women’s Federation last week. The American Medical Women’s Association celebrated its Centennial in 2015. The Federation of Medical Women of Canada was founded in 1924 and the Australian Medical Women’s Federation formed in 1927 even though Australia’s first medical women’s society was founded in 1896. In 2019, the international body to which all these associations belong, Medical Women’s International Association, will celebrate 100 years of operation, the oldest international medical association. Many of these organizations took as their inspiration the women’s suffrage movement – the theme colours of Britain’s Medical Women’s Federation are exactly those of Britain’s suffragette movement.

This means that there have been one hundred years of women physicians’ influence on medicine and health care. What has this meant for health and for the status of women physicians?

From the beginning of medical women’s organizing activity, women doctors have concerned themselves with the health of women and children and with advocating for opportunities for women doctors. All told, most of these women doctors’ organizations would likely believe that they have been more successful on behalf of their patients than on their own behalf.

Despite growing numbers of women in medicine, women continue to be underrepresented in the highest paid specialties, in university professorships, in clinical leadership positions and in most other medical leadership roles. This is true even in those countries in which women have formed the majority of the medical workforce for many years, such as China and Russia. The underrepresentation of women in powerful medical roles is of such concern in most first world medical women’s organizations that advancing the position of women doctors has become a primary concern for most of these organizations. “Equal pay for work of equal value” has its own meaning for women doctors!

As for health and healthcare, medical women and medical women’s organizations have championed women’s and children’s health, and especially women’s reproductive health. A look at the websites of any of the national organizations listed above will demonstrate this important work. The work of the members of Medical Women’s International Association (MWIA) has been so noteworthy that its projects have ensured that it has official working relations with the World Health Organization (W.H.O.).  MWIA also maintains Category II Status with the Economic and Social Council (ECOSOC) and is involved in the Immunization Programmes of the United Nations Children’s Fund (UNICEF). MWIA is represented in all three of the United Nation Centers, New York and Geneva by Permanent Representatives. MWIA is a Founding Member of the Council for International Organizations of Medical Sciences (CIOMS) and continues to be actively involved in that organization. MWIA also sends representatives to the European Women’s Lobby.

The projects of the various national organizations and of MWIA itself are as varied as its members. In recent years, MWIA has worked with ZONTA to distribute birthing kits to those women in poor countries who have their babies at home, often without any birth attendant – not even a neighbour. As well, one Past President, Dr. Gabrielle Caspar of Australia has collected ultrasound machines in that country to deliver to African countries. MWIA members from around the world are compiling a series of typical cases of intimate partner violence into a training manual for use around the world. The cases will cover an unprecedented example of cultural and social impact on intimate partner violence.

One hundred years ago, at the time that women around the world began to insist on a role in government by means of the vote, women doctors began to insist on a role in medicine that would allow them to have the impact on health, and especially women’s and children’s health, that was needed to improve health standards in general. These pioneering women physicians realized that healthcare must be equal for all. They fought for it then and continue to champion the same goals today.

(Note: The above photo is of the original members of MWIA in Geneva, Switzerland at the time of their founding meeting.)

My Predictable Clinical Life

In the past week, I have started to work on an inpatient psychiatry unit for youth. It is not easy being a psychiatrist for an inpatient program, but it is interesting and more predictable than outpatient psychiatry. In an outpatient program, emergencies arrive with little notice, often disrupting one’s schedule on days when there is no room for disruption. On an inpatient unit, the emergencies are right there in front of you all the time. This is predictable unpredictability and I find this more manageable than the frenzied calls that can disrupt an entire afternoon’s clinic.

For the past week, I have arrived on the unit to calls of, “Can I speak with you now?” or “What time are you meeting with me? I have stuff to do.” With a much smaller overall caseload than outpatient psychiatry, and patients who need to be seen daily, there is an opportunity to get to know the youth I am working with so well that their needs can be more thoroughly addressed.

The most common reason for psychiatric hospitalization for youth is to stabilize acute symptoms of psychiatric illnesses but case formulation and diagnosis and treatment plan development are becoming even more critical in youth psychiatric care. The reasons for this are embedded in the shortage of Child Psychiatrists and of youth mental health resources in general. Outpatient child psychiatry programs everywhere are stretched to the limit, to the point where the World Health Organization found that many mental health needs of youth around the world were not being addressed directly but rather through programs addressing other concerns. For example, street-involved youth often get more mental health support through housing agencies than from mental health agencies or hospital or clinic mental health programs.

Inpatient psychiatry programs and their function and purpose are not always well-understood, mostly because evidence often supports community treatment for some patients who would prefer hospitalization and hospitalization for patients who find the restrictions of psychiatric units too difficult to tolerate. This concept was summarized best by a patient I saw many years who asked me, “Dr. Beck, how come the people who want to stay in hospital can’t but the people who want to leave aren’t allowed?” When I responded, “I don’t really have a good answer for that question,” I was met with, “You don’t have any good answers.” I wish I thought that wasn’t true.

The WHO report emphasizes the need for greater collaboration between inpatient programs and the community. The social advocate in me loves the idea of working with schools, shelters, food banks and public health to develop the partnerships that will improve collaboration. The best outcomes for the clinical conditions where psychiatric hospitalization is indicated can be predicted based on social conditions. This means that those of us in who work in youth mental health must work with community partners if we are to have any success at all.

It also means that I will be diagnosing and treating conditions that go well beyond mental health into personal and social well-being. Hence, on my first day back, it was predictable that I would find myself gowned and gloved, hair covered, combing through a young person’s hair looking for nits. I can answer most questions about lice, in case anyone is interested.

Women’s Rights and Medical Women

Most of us know that the world’s leaders met this past weekend at the United Nations to discuss and commit to sustainable development goals. They formally agreed to a set of goals that they hope to bring to completion by 2030: http://www.un.org/apps/news/story.asp?NewsID=51968#.VgkpN3ldGUk

This was the second agreement of its kind, the first agreement, the United Nations’ Millenium Development Project, was launched in 2000 and, since that time, women’s groups have been measuring the extent to which these lofty goals have been addressed. These goals are outlined here and even a brief review will show that many are related to women’s empowerment and women’s health. The changes with this first set of goal have been so slow that one might wonder whether just building another set of goals will truly help. http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20Summary%20web_english.pdf

When one considers the Sustainable Development Goals developed for 2030, wondering if they can possibly be achieved, it is worth looking through the photographs on the link. Once you have, you will realize that most of the leaders discussing these are men. There are a few notable women, like Angela Merkel, but mostly men. Truthfully, on the ground, most of those actually working on the goals, getting their hands dirty and their egos bruised, are women and I want to be sure that their voices were heard and their suggestions included.

Each year at the United Nations Commission on the Status of Women, we gather into our groups and negotiate to improve and strengthen the statement and listen to talks about interventions that are succeeding in one goal. We cobble together an acceptable document only to have some state that does not value women remove certain key proposals or statements. Which states will hold women back? These include some of the Middle Eastern States and, of course, the Holy See.

Both sets of sustainable development goals are embraced by women’s groups for they represented the kind of world we wanted to leave for our children and grandchildren. Whatever the politics, it seemed as if women were more likely to get past it and get on with the work.

Women physicians, through Medical Women’s International Association, have always been involved in the consideration and development of the sustainable development goals. Each year a delegation attends the Commission on the Status of Women and lobbies for the inclusion of the most effective measures. While the progress is slow year to year, it is building. It is building to a point in the same way that women’s suffrage did. While medical women from every corner of the globe come together to provide evidence based care so that more girls and women are able to lead healthy, happy lives in careers of their choice, the world will be a better place.

This past weekend, the Federation of Medical Women of Canada met in Toronto. Like all women physicians groups, they are working toward those goals, focused on those very real Canadian concerns: poverty, domestic violence and, now, the arrival of Syrian refugees. Their numbers wax and wane as women do not always see the value of defending women’s rights until something happens to them personally to remind them that there are still barriers to woman’s advancement and equality.

At this Federation meeting, Canada’s women doctors were joined by doctors from around the world, the Executive Committee of Medical Women’s International Association. This group includes not only North American women but also women from Europe, Asia, Africa and South America. This group knows the hardship women face in getter better healthcare for themselves and their families on a daily basis and they work to improve health conditions for all.

These women are today’s suffragettes, although they are fighting for women’s status not just votes. They are also no longer going on hunger strikes. Rather, they are travelling to the United Nations and the World Health Organization and to the corners of the globe to ensure that there is a strong healthcare cornerstone in the building of women’s empowerment. Take a look at their website www.mwia.net Be inspired!

The Summer of Vaccines

Since I have come home from the World Health Assembly, vaccines have been on my mind. They have been on my mind so much that it has been impossible to think about anything else in a considered enough fashion to be able to write about it. I have been reading books about vaccines and vaccination, but I have more material than one short, pithy blog and, as well, I find that I want more information. It was the World Health Organization (W.H.O.) itself and the World Health Assembly in May that started me thinking about vaccines, so let me begin this summer series by telling you about that.

There is something about the World Health Organization Headquarters that  guards against infectious disease, that reminds me of immunization and sterile environments. It starts in the expansive front lobby of the main headquarters building with its expansive, white marble slabs, crisply laid into floors and wide steps so that dirt cannot hide and on which every speck of dust would glare from its pristine surface. “Clean me!” it screams at the end of a rainy day when mud has been tracked over the glistening expanse. From the ceiling of the foyer hang the 194 flags of member nations. Row upon row, they form a symbolic banner saluting the collective intention to make a healthier world and keep it healthy.

Outside of W.H.O. Headquarters, on the main lawn are two statues. The oldest shows a child leading a man, who is blind, a victim of river blindness. The statue honours the efforts of the W.H.O., Private Corporations, Non-governmental organizations and health care providers who have virtually eradicated this disease through a combination of judicious insecticide use and vigilant treatment. The treatment with the drug invermectin must be undertaken for fourteen  years, the length of time the worm/parasite can live in the human body.

The second statue, cast in bronze and stone, depicts a girl about to be vaccinated. The other three figures represent the health care professionals, community leaders and agencies who have supported the efforts to eradicate smallpox. This statue was erected in May 2010, on the 30th anniversary of the eradication of smallpox.

The prevention and treatment of infectious disease are among the greatest successes of medicine. In fact, medicine’s most important acts are either large or small. The small measures are the day to day care provided by health care workers to the sick or injured, the individual comforts for which individual doctors or nurses are so highly prized. The large scale measures are public health successes, like vaccines or the treatment for a debilitating disease. Normally, when I write, I focus on the small measures related to patient care but this summer, as a means to learn more about vaccines and public health, I will consider the large scale successes of health care.

Women Doctors at the United Nations Commission on the Status of Women

Returning from the 57th Commission of the Status of Women (CSW), as a representative of Medical Women’s International Association (MWIA), and having presented my work on developing resilience in young women, I want to reflect on the role that women doctors have played in women’s empowerment over the past 60 years of participation at the United Nations.

Medical Women’s International Association has been actively involved with the United Nations since the early 1950’s as a Non-Governmental Organization (NGO). The organization maintains official working relations with the World Health Organization, Category II Status with the Economic and Social Council (ECOSOC) and is involved with UNICEF’s Immunization Programs. MWIA has Permanent Representatives in all three United Nations Centres and in New York City and Geneva.

Each year. MWIA brings together a delegation of its members to the UN Commission on the Status of Women in early March. All members of the delegation are self-funded and volunteers. This year’s priority theme was the Prevention and Elimination of Violence Against Women and Girls. Because violence against women and girls is so closely linked to health, as well as empowerment, the contingent of participants was larger than usual and MWIA sponsored three events at the Commission, including one sponsored by the Government of Canada in which the Parliamentary Secretary to the Minister Responsible for the Status of Women, Suzanne Truppe, participated.

In order to understand the accomplishments of the CSW, one has to be aware that the the final outcome is contained in “Agreed Conclusions” reached at the end of the meeting. Last year’s CSW was marred by the fact that negotiations between the various members never reached “Agreed Conclusions”. Because of this, and because of the importance of this year’s priority theme, the atmosphere was tense among NGO’s, all concerned that the same will happen this year. For MWIA, an organization whose members have been working to prevent violence against women and girls since their founding in 1919, “Agreed Conclusions” would assist our members in many countries to promote initiatives and programs of immediate benefit to their patients.

The work of MWIA in the prevention and elimination of violence against women and girls concerns not only the impact of violence on physicial and mental health but also the impact on women’s empowerment. This is of such great importance that women doctors, residents and students presented reports from four of our eight regions to the Commission. The regions included North America, South America, Near East and Africa and the Western Pacific Region. Despite aconomic and cultural differences across these regions, the themes are strikingly similar: the need for women to access good information and appropriate timely care; the need to promote the education and resilience of girls; and the need to combat the significant misinformation and prejudices that still exist with respect to reproductive and mental health. The body of MWIA’s work in these areas can be found on their websie at http://www.mwia.net.

Members of MWIA in all regions are powerful advocates for women’s empowerment in reproductive health and, in fact, one could argue that women physicians’ authoritative voice in reproductive health has ensured that evidence is not forgotten when policy is developed. Like other NGO’s, MWIA is discouraged that policy in reproductive health is so often influenced by cultural myths and not scientific evidence.

For those who have an interest in the draft “Agreed Conclusions”, these can be found at  http://www.un.org/womenwatch/daw/csw/csw57/CSW57_Draft_AC_proposal_presented_by_CSW_Bureau_8_February_2013.pdf.

The presentations of MWIA’s participants can also be found on the MWIA website. Those following this blog will recall that I had asked Dr. Pam Liao to talk about the project between MWIA and Next Gen University that she is developing. This project to develop educational materials garnered much interest both times it was presented. MWIA has developed training manuals previously that have been used to assist health care providers around the world to develop their knowledge and this newer educational model will continue to promote better education for care providers.

As I write this, it is not clear whether this year’s negotiations will actually produce a document of “Agreed Conclusions” but there are a number of member states and NGO’s very determined that Violence Against Women and Girls is such a serious problem worldwide that a unified voice is needed. As the meeting began, 41 member states had already agreed that action must be taken to end violence against women and girls. This is a hopeful sign, especially since both the African and South American States are included in the declarations.

Finally, as I am publishing this on Sunday afternoon when you may have an extra minute or two, I invite you to listen to this song, developed for UN Women and International Women’s Day. Puchase it and promote it, please, to help fund UN Women in its work:http://www.youtube.com/watch?v=Dnq2QeCvwpw