Towards justice in health [full issue]

VK)RLD HEALTH THE MAGAZINE OF THE WORLD ORGANIZATION • JULY 1979 Towards Justice in Health Towards justice in health by Dr T. Adeoye Lambo Deputy Director-General, World Health Organization "By 'faith in man' we mean here the more or less active and fer- vent conviction that mankind as an organic and organized whole possesses a future: a future consisting not merely of success- ive years but of higher states to be achieved by struggle ..." (Pierre Teilhard de Chardin: "The Future of Man") ince the other contributors to this issue have dealt adequate- ly with specific aspects of health and human rights, this introduction will focus abrasively on the dialectic of Man's future in spite of the socio-economic and political constraints that surround him and alienate him, im- pede his self-reliance, undermine his rights in determining his future. Every man, in every society—simple or complex—has his own horizon, beyond which his pretensions do not ex- tend. They reach the edge, but they do not cross it. That which a man is in him- self, that which accompanies him into solitude, and which none can give him or take from him, is necessarily more essen- tial than all that he may possess or all that he may appear in the eyes of others. The supreme and all-important elements of happiness and fullness of life are sub- jective possessions, such as noble charac- ter, a capable mind, an easy disposition, and a well-organized and healthy body; and it is these "gifts", many non-western cultures rightly insist, that should be cul- tivated and preserved, even at the ex- pense of wealth and emoluments. The claims of contemporary western societies to possess high-powered tech- nology and wealth, and the excessive rel- iance they place on these material possess- ions in an effort to keep in the swim, are not very conducive to the quality of life so earnestly desired by non-western societies. Indeed, it may fairly be said that the latter hold in utter contempt the entire machinery of modern technology, and look upon the whole thing as a toy for imbeciles. Nothing more clearly illustrates the need to reform the present imbalanced and lopsided socio-economic order, as well as to promote total human well-be- ing, than the recurrent crises that have overtaken the world during the last decade. It is now over 35 years since the United Nations Charter was signed and inaugurated in an international effort to establish a new international order. This constituted one of the most striking and hopeful features of the UN. Among many obscure pronouncements on humani- tarian ideals and the kinship of men were some concrete instruments aimed at achieving greater human ends, or meet- ing human aspirations; they sought to guarantee security and needs in a new human context, and to formulate a poli- cy by the great "civilized" governments to extirpate social and economic slavery from the world. These aims were thought to be right. What is right, however, need not necessarily be true. Today, that inter- national order has reached a critical turning point; its hopes of creating a bet- ter life for the whole human family, and of transforming society, have turned out to be illusory. It has proved impossible to meet the minimum health and social needs. On the contrary, more are today hungry, sick, shelterless and illiterate than when the UN was first set up to erase all these inequalities and the dearth of opportunities. At the same time, new and unforeseen concerns in the field of human rights have begun to darken the international prospects. Environmental degradation, the lack of a clear-cut strategy to im- prove human conditions, the question- able moral conduct of big powers and the rising pressure on resources—all these raise the question whether man's social integrity may not be at risk. And to these preoccupations must be added the realization that the next three decades may bring a doubling of world population. Another world on top of this one, equal in numbers, demands and hopes. These critical pressures need give no reason to despair of the human enter- prise, provided we undertake the neces- sary changes. The first point to be under- lined is that the failure of world society to provide "a safe and happy life" for all is not caused by any present lack of phys- ical resources. The problem today is not primarily one of absolute physical short- 2 Cover: An appeal .6* ' for justice in health '„'" Nit . ,... that cannot be ignored. ':*1 ...*** 4( k, (Photo ....0•At , Thierry Dallant t) ..•v., r f.flow . Ammo -rye 1 IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor: John Bland Deputy Editor: Christiane Viedma Art Editor: Peter Davies News Page Editor: Lalit Thapalyal World Health appears in Arabic, English, French, German, Italian, Persian, Portuguese, Russian and Spanish. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. WHO lines up squarely with the unprotected, the deprived, the exploited, not only in their rejection of mere materialism but also in their insistence on the priority of the quality of life, of love, and of hope. ("The Tree of Life"; drawing by Ana Maria, aged 12, of Spain, reproduced by courtesy of Reidda Barnen, Sweden © ) age but of economic and social maldistri- bution and misuse; mankind's predi- cament is rooted primarily in economic, social and political structures, and in behaviour within and between countries. Much of the world has not yet emerged from the historical conse- quences of almost five centuries of colo- nial control which concentrated econom- ic power so overwhelmingly in the hands of a small group of nations. To this day, at least three-quarters of the world's in- come, investment, services and almost all of the world's research are in the hands of one-quarter of its people. The devel- oping nations are still struggling with the problem of how to bring about socio- economic equity and a palpable im- provement of their lot. What is happening around us shakes our complacency, challenges our faith in human progress and imbues us with an intense feeling of shame, doubt and guilt. In a world where the gigantic scientific and phenomenal technological achieve- ments command our admiration and al- most fetish acceptance, we are witnessing an intolerable degradation of man. Our Contents Towards justice in health by T.A. Lambo 2 Women, health and human rights by H. Sipila .. ... 6 Alma-Ata: signpost to a new health era by W. L. Barton ..... 10 Dying children need help too by J.A. Chapman & J. Goodall . 16 Medical ethics: a viewpoint from the developing world by J.S. Neki 18 "I swear by Apollo..." by C. Viedma 24 News Page 30 Towards justice in health pride in belonging to a generation that for the first time since the genesis of man has set foot on another planet cannot, however, disguise the awful truth that it may be easier to travel to the moon than to erase from the surface of the earth the im- age of inevitable poverty, human exploita- tion, injustice and the degradation of human welfare. Our first concern is to redefine the whole purpose of development. This should not be to develop things but to develop man. Human beings must have basic needs : food, shelter, clothing, health, education. Any process of growth that does not lead to human fulfilment— or, even worse, that inhibits it—is a travesty of the idea of development. We are still in a stage where the most impor- tant concern of development is the level of satisfaction of differential needs for the poorest sections in each society, which can amount to as much as 40 per cent of the population. The primary pur- pose of socio-economic growth and development should be to ensure im- proved conditions for these groups. A development process that benefits only the wealthiest minority and maintains or even increases the disparities between and within countries is not development. It is exploitation. And the time for start- ing the type of true development that leads to better distribution, and to the satisfaction of minimum but effective needs for all, is Today. We believe that the pious hope, held for more than 35 years, that rapid economic growth bene- fiting the few will "trickle down" to the mass of the people has proved to be illu- sory. One is justified, therefore, in reject- ing the idea of "growth first, justice in the distribution of benefits later". For those who have at heart the ad- vancement of man, especially as it relates to health, the first and strongest feeling must be gratitude to the spirit of the Alma-Ata Conference. Primary Health Care, judiciously followed by "Health for All by the Year 2000" is, to me, the outward sign by which the future histor- ian will trace the onset of the health rev- olution. These are great historic moves to meet the need for a new, integrated and compelling vision of human destiny. WHO's new attempts to foster, through the UN system, the emergence of human- ity in a new and superior state, and to construct the picture of man's develop- ment as involving an inevitable progress towards total well-being, have broken down the traditional barriers between medical disciplines. It is not even a ques- tion of building bridges between immun- ology and cancer, between vector biolo- gy and malaria and other parasitic dis- eases, between mental health and human reproduction, but rather of fusing together these programmes and these basic scientific disciplines in a fundamen- tal way. The very fact that we are so keenly aware of, and globally concerned with, our inadequacies, the social, economic and political imbalances, and the erosion of social justice and human rights is the best sign that we are going to find solu- tions for them. The mere presence of danger is no reason for nervous dread; indeed, to the healthy, normal individual the spice of danger is apt to be rather a challenge and an inspiration. Only when peril looms overwhelming and inescap- able does despair chill the heart and paralyse the will. And surely no well-in- formed observer of our times can dog- matically assert that we are in any such hopeless posture. Haves and have - nots It seems to me that the outstanding feature of contemporary world affairs is one of profound and general disharmony between the two polarized groups—the "haves" and "have-nots" ; the rich are getting richer and the poor are getting poorer and more frantic, resulting in an endless maladjustment, perplexities and conflicts. The immensity of the human problems calls for revolutionary thinking and action unprecedented in human his- tory. In my view such a "revolution" must affect every phase of human activi- ty, girdle the entire globe, and involve all mankind in order to produce adequate human resources, dynamic and content- ed new societies, with the support of technologies that are not divorced from basic human realities. This is the first time in history that the Third World has consciously and with determined purpose embarked on the task of directing its own fortunes, fired by a sense of radical moral optimism. Hitherto, it has been a puppet in the cruel and cunning hands of the "major- power" monopolies. There can be no doubt today that the Third World has the intellectual grasp and emotional poise necessary for the task of "going it alone". Such a move does not spring from an impulsive idealism but is charac- terized by a keen sensitiveness to our pre- sent social evils and by a comprehensive grasp of the whole situation. Yet over large parts of the world that we now call the Third World, the quality of collective life continues to deteriorate; the potential for social and economic reconstruction continues to be sapped. In the deliberations of the organizations of the UN system, delegates from the Third World can find here and there notions that awaken enthusiasm, broad vistas, and startling constructive ideas ; but they may also experience difficulty in grasping the coherence of the views pro- pounded. The growing emotionalism of our times in the Western world involves a corresponding diminution of the rational, tolerant attitude best described as "liberalism". This decline in the quali- ties of open-mindedness, readiness to hear and discuss other viewpoints, re- spect for differences of opinion, and downright common-sense reveals a truly amazing paradox between the way we ac- cept the material benefits of modern science and technology, and at the same time reject rational processes of human- ization. All this can be seen in the contra- dictions that feature so prominently in the attitudes and behaviour of some of the developed countries to contemporary socio-economic and political matters which impinge upon human rights and national identity in the developing coun- tries. The reformers of the Third World seem so fired by the sense of present evils that they have to embrace non-orthodox gospels in order to generate new forces and ideas. A wholly new set of motives for social order can be conceived, which do not rest on any of the old institutions of the West nor on the rather "renovat- ed" neo-colonialistic ones of non-capi- talist countries. The problem of human degeneration, degradation and exploita- tion is a life-and-death question, involv- ing not merely the fate of modern civil- ization, but possibly the entire future of mankind. We must continue to ask our brothers from the developed countries to understand our unbearable allergy towards every brand of alienation, especially socio-economic and political alienation. 4 Our objective must be to build a future for man in which he will not be deprived of any of his dimensions—health, social justice, and eco- nomic freedom; where he will be a "whole" man. ( Photo World Council of Churches) Given the objectives of WHO's Consti- tution and the Organization's strategies for Health for All by the Year 2000, a determined search must be undertaken both by the Member States and by the Organization itself to discover the fun- damental components in that which gives meaning and value to our lives, whether in a New International Socio- economic Order, in Christianity, or in Marxism. Then, after eliminating what is ancillary and contingent, we must deter- mine whether at this fundamental level there are sufficient intersecting areas to allow us, working together as nations and without hidden motives, to build a future for man in which he will not be deprived of any of his dimensions— health, social justice and economic free- dom; where he will be in Karl Marx's phrase a "total" man, in Teilhard's phrase a "whole" man. WHO's bold stand and strategy on the future total well-being of man should not be seen as a cosy conversation-piece for self-indulgent intellectual soirees. In the strategic plan for Health for All by the Year 2000, the analysis of human exis- tence and the quality of life incorporates, in its structure and content, an inescap- able call for decision and action on the part of Member States and governments. No Member State can in fact opt for neutrality before this stream of life. It is an undertaking which explicitly or impli- citly involves any social, political, scien- tific, technological, educational, inter- racial, cultural or other motivation which is authentically concerned with the future of man and his total well-being on this planet. The strategy is incontestably a pragmatic and pressing one, and a far cry from mere utopianism. It has further- more opened up a perspective for con- structive and fruitful dialogue on health matters between Member States, irres- pective of whether they are socialist or capitalist, developed or developing. WHO lines up squarely and unequivo- cally with the unprotected, the deprived, the exploited, not only in their rejection of mere materialism but also in their in- sistence on the priority of the quality of life, of love, and of hope. Despite the apparent polarization that is occurring, despite disenchantment with the prevailing international socio- economic order, despite allergic reac- tions to exploitation and alienation, there is still, at the level of health and at the level of a collective search for solu- tions to many major diseases, unity. Hope in the growing unity of mankind can never be misplaced hope. My contribution to this issue of World Health is an attempt to explore and cir- cumscribe certain areas of meaning which are of prime importance for our understanding of the social and econom- ic forces of today's world. Despite the shortcomings and undeniable limitations of this approach, it does, however, repre- sent an attempt by a medical scientist to project an overview by arguing again and again for the need of modern man to develop, animate and sustain a dynamic, future-oriented vision of himself and the universe around him. ■ 5 Women, health and human rights Equality of men and women, women's full involvement in the development of society, and their increasing contribution towards strengthening world peace—these objectives became the theme of the UN Decade for Women by Helvi Sipila n 10 December 1948 the United Nations General As- sembly adopted and pro- claimed the Universal Dec- laration of Human Rights. Article 3 of that Declaration states : "Everyone has the right to life, liberty and the security of person." In article 25 it is stated : "1. Everyone has the right to a stan- dard of living adequate for the health and well-being of himself and of his fam- ily, including food, clothing, housing and medical care and necessary social ser- vices, and the right to security in the event of unemployment, sickness, dis- ability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 2. Motherhood and childhood are en- titled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social pro- tection." Thus it may be seen that the right to health is one of the fundamental human rights of the individual. This concern for the health of the indi- vidual did not appear for the first time on the international scene in 1948. It had been discussed before. The International Labour Organisation (Ow) had been in- volved with the health of workers even before the foundation of the United Nations. Furthermore, the United Nations Charter itself specifically refers to health in at least three articles. In art- icle 13 it calls upon the General Assembly to initiate studies and make recommen- dations for the purpose of: "(b) promoting international co-oper- ation in the economic, social, cultural, educational and health fields, and assist- ing in the realization of human rights and fundamental freedoms for all without distinction as to race, sex, lan- guage or religion." In Chapter 9 of the United Nations Charter on International Economic and Social Co-operation, the United Nations is called upon, under Article 55 (b), to promote "solutions of international eco- nomic, social, health, and related prob- lems". And in Article 56 all Member States pledge themselves to take joint and separate action in co-operation with the Organization to achieve the purposes set forth in Article 55. The Economic and Social Council is empowered, under Article 62, to initiate studies and reports with respect to inter- national economic, social, cultural, edu- cational, health, and related matters, and may make recommendations with re- spect to any such matters to the General Assembly, to the Member States and to the specialized agencies concerned. From the foregoing it may be said that the issue of the health of the individual has been the concern of the international commu- nity for about half a century. Subsequent instruments prove its continued impor- tance to and occupation of the family of nations. Special needs of women The special health needs of women emerge right from childhood. Because of the high infant mortality rates that still exist in many parts of the world the need to bear as many children as possible im- poses a special burden on the health of women. This problem becomes even more complex where children are viewed as a sign of wealth or where customs em- phasize the importance of a large family. Under these or similar conditions the woman is subjected to great tension and pressure to bear children, with the result that both the mother's and the children's health suffers. Often this contributes to infant mortality, which in turn re- enforces the pressure to bear more children. When children survive, the availability of food is frequently not adequate to en- sure to each child, mother and father the minimum daily nutrient requirements. Consequently the health of the family is greatly undermined. In order to ensure adequate food supply, the entire family, and women in particular, are usually forced to labour for long hours tilling the land, or working in factories, with the result that children are not well taken care of; the parents are too exhausted to provide the proper care necessary, so that the health of the entire family is jeopar- dized. It is situations such as these that have for years led to the establishment of various governmental and non-govern- mental organizations attempting to deal with problems of the health of the indi- vidual. At the United Nations, the Com- mission on the Status of Women, which is a functional commission of the Eco- nomic and Social Council, has been the body primarily responsible for women's issues right from the beginning, since 1947. The efforts of this Commission as well as those of other United Nations organs and bodies, specialized agencies and non-governmental ' organizations received a fresh momentum following the proclamation of 1975 as Interna- Woman the load-bearer. When the physical burden on a young mother is too great, the health of the whole family may suffer. (Photo WHO/J. Mohr) 6 1 "v`>.~:. tional Women's Year and the convening in Mexico City of the World Conference of the International Women's Year from 19 June to 25 July of that year. The World Conference adopted two important documents : the "Declaration of Mexico" and the World Plan of Ac- tion. The Declaration affirmed its faith in the objectives of the International Women's Year which were : equality of men and women, women's full involve- ment in the development of society, and their increasing contribution to the strengthening of world peace. These same objectives later became the theme of the United Nations Decade for Wom- en, 1976-1985—equality, development and peace. The World Plan of Action calls upon governments to ensure "improved access to health services, better nutrition and other social services that are essential to the improvement of the condition of women and their full participation in development on an equal basis with men". The Plan of Action further states: "Individuals and couples have the right freely and responsibly to determine the number and spacing of their children, and to have the information and the means to do so. The exercise of this right is basic to the attainment of any real equality between the sexes and without its achievement women are disadvan- taged in their attempt to benefit from other reforms." Equality of the sexes In order that there can be real equali- ty, both men and women must be given equal access to whatever is available. It is often stated that poor nations do not have enough amenities. The question is, therefore, how can they talk about ac- cording equality to women under such circumstances? On the other hand, it is obvious that as long as only a few people enjoy the amenities that are available, the amenities themselves will continue to be scarce. Yet if all people are treated equally, regardless of the scarcity or abundance of the amenities, such sharing may bring about improvement. With specific reference to health facili- ties, if doctors and hospitals are spread throughout the country including the rural areas, as opposed to being concen- trated in the cities, this will obviate the need for rural people to migrate to the cities. Moreover, since the greatest im- portance must be given to preventive measures, placing health care facilities within the reach of the rural people and making them partners in the health care system will lead to improvement in their health and an increase in food produc- tion. Nevertheless, providing all citizens with health facilities is simply a fulfil- ment of the obligation to honour their human right—the right to an adequate health standard. Since women tend to be left behind in the rural areas when men migrate to the urban areas, to ensure for them access to health facilities in the area where they live would be a major step towards equality. Development and Peace In the past two decades the issue of development, especially economic devel- opment, has acquired priority over all other issues. Indeed the fact is under- scored by the first, second and third development strategies (the latter is now being negotiated) and by the New Inter- national Economic Order itself. Yet, is it really possible to achieve development without a healthy individual? If by development we mean increase in productivity, it is essential that the indi- vidual should be maintained in good health. With special reference to women, it must be stated that women have always been producers. They can be found working on farms to produce both food and cash crops; they may also be found in markets distributing the goods they have produced. In industrialized societies women can be found in factor- ies and in offices. Women are therefore not strangers to the labour force. However, in order that women may con- tinue to participate in economic activities they must be accorded access to health facilities. The World Plan of Action states: 8 Women, health and human rights Left : "A woman's work is never done" whether she is tilling the soil, marketing the produce, carrying water, cooking for her family, or car- ing for the children. ( Photos L. Solmssen, League of Red Cross Societies, and WHO/D. Deriaz) Right: Immunization protects the family. The 1975 World Plan of Action stated: "Improved ac- cess to health, nutrition and other social ser- vices is essential to the full participation of women in development activities, to the streng- thening of family life and to a general improve- ment in the quality of life." ( Photo I. Guest ©) "Improved access to health, nutrition and other social services is essential to the full participation of women in devel- opment activities, to the strengthening of family life and to a general improvement in the quality of life. To be fully effective these services should be integrated into overall development programmes with priority being given to rural areas." Moreover, it must not be forgotten that women are not only producers of goods and services but also of the labour force itself! As mothers, women need special health services which are not required by men. In recognition of this, the World Plan of Action also calls upon governments to pay particular attention to women's special health needs by pro- viding "pre-natal and post-natal and delivery services; gynaecological and family planning services during the reproductive years ..." At the World Conference of the Inter- national Women's Year, it was stressed that the peace efforts of women as indi- viduals and in groups must be recognized as essential for the maintenance and strengthening of international peace and co-operation. As in the case of develop- ment, the health of women is a prerequi- site for their involvement in peace ef- forts. Besides concern for the general welfare of humanity, women—like men—are concerned about the arms race which threatens the very existence of humanity. It has been shown that leak- ages of radio-active material into the at- mosphere can have more adverse effects on women, especially pregnant women, and also that the women so affected might not know about it for as long as 30 years. Thus the arms race, whose probable dangers continue to be dis- cussed, may already have affected the health of many women. In places which are subjected to for- eign domination and occupation, viola- tions of human rights occur and these in- clude the violation of the right to ade- quate health standards. Usually women tend to suffer more than men. In South Africa, for example, where the system of apartheid deprives non-whites of fun- damental human rights, it has been found that non-white women suffer par- ticularly severe deprivation. In a report of the Secretary-General before the Commission on the Status of Women, at its twenty-seventh session, it was stated that non-white women are often restrict- ed to the reserves where health facilities are most inadequate. Employment, Health and Education At its first regular session in 1978, the Economic and Social Council adopted a resolution entitled "Sub-theme of Em- ployment, Health and Education for the World Conference of the United Nations Decade for Women". This stated that the three areas of employment, health and education are of primary concern to Member States today in their endeavours to achieve the objectives of the United Nations Decade for Women: equality, development and peace. It recommended that the United Nations World Confer- ence of the Decade for Women, which is going to take place in Copenhagen in July 1980, should place emphasis on ela- borating new strategies for integrating women into the development process, particularly by promoting economic and employment opportunities on an equal footing with men through, inter alia, the provision of adequate health and educa- tional facilities. The preparatory work for the Conference is being carried out accordingly. Among the sectoral meetings which have taken place, preceding the Confer- ence, was the International Conference on Primary Health Care held at Alma- Ata, in the Soviet Union, from 6 to 12 September last year and sponsored jointly by WHO and UNICEF. Other meet- ings on aspects of health affecting wom- en have also been organized. These indi- cate a quick response to the call by the Economic and Social Council for in- creased attention to be devoted to the sub-theme. It is hoped that the second half of the United Nations Decade for Women will witness increased attention to these very important aspects of wom- en's rights. ■ 9 Alma-Ata: signpost to a new health era The Alma-Ata Declaration has given a clear definition for the new "Era of Political Health Science", through the implementation of the primary health care approach by W. L. Barton he International Conference on Primary Health Care, held in the capital of Soviet Kazakhstan last September, resulted in the Declaration of Alma-Ata which reaffirmed health as a fundamen- tal human right and a worldwide social goal. It sounded a call for urgent and ef- fective national and international action to implement primary health care throughout the world, as part of "devel- opment" in the spirit of social justice. For those responsible for achieving the objectives set out in the Declaration and for implementing the 22 specific recom- mendations adopted at the same time, it will require not only the acquisition of certain new skills but also changes in at- titudes relating to a new emphasis in the philosophy and the educational and research needs for the era of health science that lies ahead, up to the year 2000. The fact that the Conference occurred at all must surely have resulted from the realization that improvements in the world's health have not run parallel to the modern scientific practice of medi- cine, and that medical practice has not taken full advantage of the knowledge and tools provided by science in various other fields. In this post-conference stage, it would seem an opportune time for those in pub- lic health to reflect on the present posi- tion of health science and to define more clearly the main direction of the "new era". Before doing so, however, it may be helpful to review briefly the develop- ment of health science as it has occurred over the last century, in order to see what lessons can be learned. Three profound changes in emphasis in medical practice took place between the 1850s and the 1950s. These were suc- cinctly described in 1956 by Dean Ed- ward G. McGavran of the School of Public Health in the University of North Carolina, who identified at the same time four major health science eras. For each era he described the changes, relating them to philosophy and purpose, educa- tion, research and the role of behavioural sciences. These can be summarized as follows : Empirical Era: Prior to 1850, the focus was on the diagnosis and treatment of the symptoms and signs presented by the patient. The V.I. Lenin Palace at Alma-Ata, in Soviet Kazakhstan. ( Photo WHO) Right: The Era of Political Health Science recognizes that the foundations of ill-health are laid by basic human suffering... (Photo Thierry Dallant While several hospitals and medical schools had been established, it was quite usual for doctors to be trained by ap- prentice attachment to well-established medical practitioners and thus to become eligible for medical registration. Educa- tion was essentially by authoritarian in- struction and example, while research was basically historical with searches into the teachings and practices of earlier physicians; the behavioural sciences were unknown. Era of Basic Science: With the dis- covery of the animal cell and later the demonstration of bacteria, a scientific ex- planation could at last be given for the causation of disease. The sign and symp- tom took on a new significance as point- ers to the disease process. The basic scientists became the leaders of medical education and research, which concentrated, with intensity, on developing new tools for laboratory research and instruction in laboratory techniques. The focus in philosophy moved to the diagnosis and treatment of disease. For clinicians, the introduction of the use of the clinical thermometer in 1866, the sphygmomanometer in 1881, and the electrocardiograph in 1903 provided fur- ther tools in the diagnostic process. But although individual activity was occur- ring, the behavioural sciences were not considered to be needed in medical prac- tice. Era of Clinical Science: The first half of this century saw the era of clinical science as a natural development in time, with the focus swinging from the disease to the patient and the individual. The patient with his disease became the cen- tre of investigation; psychological medi- cine and sociology with its clinicians demonstrated that disease could no longer be treated in isolation ; the social sciences now became an adjunct to medi- cine, with speciality groups involved. Era of Public Health Science : The development of antibiotics and insecti- cides in the 1950s provided the "golden age" of chemotherapeutic agents (an ex- 1 0 • Alma-Ata: signpost to a new health era Left: The .first half of this century saw the Era of Clinical Science as a natural development in time, with the focus swinging from the disease to the patient and the individual. The patient with his disease became the centre of investiga- tion... ( Photo WHO/P. Almasy) Right: Ancient and modern transport in the Eastern Mediterranean Region. During the Era of Public Health Science, people realized that what had once been regarded as insuperable difficulties in the way of health development, particularly in the less developed areas of the world, no longer constituted technical barriers to progress... ( Photo WHO/E. Schwab) pression used by Bernard Dixon in his recent book "Beyond the Magic Bul- let"), and a further change in philosophy and purpose was seen to occur. This en- tailed an understanding of man in rela- tion to his total environment, with the emphasis directed towards the diagnosis and treatment of community illness rath- er than the individual patient. Dean McGavran described this era comprehensively and showed the need for research to be directed towards the development of community measure- ments and criteria, and community development techniques; the inter-disci- plinary team approach was introduced with the social sciences integrated therein. The new patient became "the commu- nity", requiring from the physician an understanding of how such an aggregate of individuals functioned, as well as rec- ognition of the role of cultures, values, norms and human behaviour in commu- nity disease patterns and their causation. With the new tools it was realised that what had once been regarded as insuper- able difficulties in the way of health development, particularly in the less developed areas of the world, namely malaria and other parasitic insect-borne diseases, no longer constituted technical barriers to progress. It was felt that the means by which almost all such major diseases could be brought under the hammer of prevention, control and erad- ication were well understood. As the late Professor George Macdonald of tropi- cal hygiene renown stated at the time, there appeared to be no major problems for the health team. For the last 28 years the public health profession has aimed its efforts at the community as the patient. While it can be said that much has been achieved in certain specific communities with certain specific diseases, it has been gradually realized that—apart from the often dra- matic and exotic diseases which may dominate the health picture in a commu- nity—the true foundations of ill-health in all societies still lie in nutritional defects, ignorance of the methods of care of children and the handicapped, infec- tions and conditions of the alimentary tract, chest conditions, high fertility rates, and the high risks of life as in child-bearing or certain occupational hazards. Added to these in more recent times have been the new hazards that have resulted from man-made changes in the ecology—water or irrigation devel- opment projects, the production and use of chemicals, industrial development with its various pollutants. Today there is an increasing realiza- tion that true health for a community cannot be brought about by an approach on individual lines; an unhealthy com- munity is not raised to the standards of a healthy community merely with the 12 removal of a disease; medicine is no sub- stitute for health; health services have had little to do with the health of the people. Attempts at community medi- cine imposed from outside have ap- parently failed to provide health for all because of a disrespect for the people's own health culture. The concentration on community disease overlooked the needs of certain underprivileged and un- derserved sectors ; the pattern of tubercu- losis, yaws, trachoma, malaria in the community attracted more attention than malnutrition and the consequences of other socio-economic deprivations; "disease" was the preoccupation, rather than the maintenance of "health". The Alma-Ata Conference heralds a new era, reinforcing and expressing in concrete terms the theme of the 1977 Dag Hammarskj old Foundation Semi- nar (held in Uppsala, Sweden), "Another Development in Health". The summary conclusion of that Seminar called for the need to redefine the concept of health, taking into account the socio-economic and socio-cultural determinants of the health condition which cannot be deter- mined by health care systems ; it is a commodity which cannot be purchased; and it is a responsibility of the individ- ual, community and government as a whole, therefore ultimately a political question. Are we not witnessing an entry into a new epoch with further changes in em- phasis? This might become established as the "Era of Political Health Science", with an emphasis no longer on the philo- sophy and concept of the community as patient, and with identified community illnesses being treated through an inter- disciplinary approach, but rather on "the people", the entire population; with a recognition that the foundations of ill- health are laid by basic human suffering, requiring an inter-sectoral approach to alleviate them and to bring about an eventual improvement in the quality of life. In describing the emphasis for concern in the earlier "Era of Public Health Science", Dean McGavran used the term "the body politic", seeing this as the final stage of the philosophy and purpose of the community concept. In the develop- mental stages of that era, however, the emphasis of education and research remained within the confines of the med- ical and professionally related disci- plines. This term can now be more ap- propriately adopted for the new era, referring as it does to the total body politic : mental, physical, social, econom- ic and political. The interplay between health and socio-economic development has become one of the key political issues of the day as a safeguard for human rights. The new philosophy and purpose relating to the body politic lays an em- phasis on providing all people with a 13 DEVELOPMENT OF MEDICAL SCIENCE UP TO THE YEAR 2000 from the empirical era to the era of political health science EMPIRICAL HEALTH ERA BASIC SCIENCE ERA CLINICAL SCIENCE ERA PUBLIC HEALTH SCIENCE ERA POLITICAL HEALTH SCIENCE ERA PURPOSE AND PHILOSOPHY Symptom-centred 1850 Bacteria- or Dis- ease-centred 1900 Patient-centred 1950 Community-centred 1975 2000 People-centred Empirical diagnosis and treatment of symptoms Diagnosis and treat- ment of disease Diagnosis and treatment of the individual Diagnosis and treat- ment of the community Diagnosis and treat- ment of total body politic EDUCATION Lectures Authoritarian instruction Laboratory instruction Clinical instruction Bedside teaching Clinical public health instruction Community-side teaching Social experience learning Social and economic understanding Managerial acumen Political psychology and process Country health programming RESEARCH Historical Basic Laboratory Development of new tools Clinical develop- ment of clinical techniques Community Development of the community Measurements and criteria Planning techniques Social and economic indices for health development Subjective indices for quality of life Intersectoral activity process Network process BEHAV - IOURAL SCIENCE Unknown Not needed Individual activity Ancillary Social sciences— an adjunct to medicine Speciality group necessary Integrated Social sciences Sophisticated skills Co-equal with public health science Inter-disciplinary team Inter - related Social, health, eco- nomic and political sciences Inter-sectoral team chance to live their lives in health by the end of the present century. As indicated last year in the address to the Thirty-first World Health Assembly by Dr Halfdan Mahler, Director-General of the World Health Organization, the era ahead calls for a new managerial competence with a combination of scien- tific and technical knowledge and politi- cal persuasiveness. For public health physicians the new emphasis, in educa- tional terms, must therefore be on pro- viding a wide range of knowledge and skills for a broad social and economic understanding; country health pro- gramme development; management acu- men; the political process and how it op- erates; political psychology and how it is controlled. Research will need to be developed towards the social indices for health and health development, towards subjective indices for the evaluation of develop- ment and the quality of life, towards the inter-sectoral activity process. The behavioural science involvement in the earlier eras now extends to other sciences in the economic and political spheres. All sectors are involved; each has much to learn from the other. If this era is to have success there must be a move from the concept of health as being the total responsibility of a profess- ionalized service to a new emphasis on self-reliant health care. As the Uppsala Seminar concluded, this entails a sincere political determination for complete democratization in the community whereby equity exists, not only in the dis- tribution of assets, but especially in the making of decisions which concern the people and their health. Access to infor- mation on health must be available to all—to individuals, the local community, government officials and politicians alike. The emerging science of the new era calls for a clear definition of objectives, purpose and function, so as to identify the required competence, distinctive skills and body of knowledge in terms that can be clearly understood by the people and the politicians, as well as by the professional leadership involved. It demands daring leadership, not afraid to step forward from the basic professions Right: "Health for All" in Africa. The em- phasis is no longer just on the philosophy and concept of the community as patient, but rath- er on "the people"—the entire population ... (Photo WHO) from which they came, to face the chal- lenges and difficulties of education in the new fields and to direct with courage, through competence in public health, the team of equals. The Alma-Ata Declaration has given a clear definition and clarity of purpose and function for the new health era, through implementation of the primary health care approach. It acknowledges the fact that the successful development of environmental, community and indi- vidual health cannot be undertaken without a major medical involvement and a health system designed to support and complement the front-line workers. And it calls on leadership from members of the health team, who must either ac- cept the challenge or be prepared later to step back and see others take over the leadership that could have been theirs. ■ 14 s . he control of symptoms in dy- ing children is often sadly neglected. This neglect is reflected in a review of the case notes of two children who died of cystic fibrosis (fibrous degeneration of the pancreas) within three years of each other. The girls were under the care of the same consultant, who in the interval between the two cases was introduced to the concept of proper terminal care for children. Child 1 This child was found to have cystic fibrosis at the age of six weeks, her parents having already had two affected children. Her clinical course was typical of the disease. At the age of nine years she was admitted after a week of increas- ing breathlessness and troublesome, pro- ductive cough. She was breathing with difficulty, cyanosed (showing discolora- tion of the skin due to deficient oxygena- tion of the blood), and feverish. Her chest signs and radiograph were charac- teristic of fibrocystic disease with added infection. She was at once put into a humidified oxygen tent and encouraged to drink. Her maintenance antibiotics were changed and physiotherapy was intensi- fied. After admission her condition deteriorated, so fluids and antibiotics were given intravenously from the second day. She was cyanosed and rest- less but conscious, orientated, and un- able to sleep. On the sixth day she went into congestive cardiac failure, requiring drug treatment with frusemide and digoxin. During the six days she had been seen often but inconsistently by three senior house officers, two regis- trars, and two consultants—holidays and off-duty periods interfering with contin- uous care by any one doctor. Active management continued, with numerous blood gas analyses and several changes in antibiotics, but staff were clearly slow to realize either that she needed relief for her symptoms or that this was a terminal illness. On the seventh day the nursing notes repeatedly stated that she was "very poorly" and "has not slept". She had also complained of pain, for which paracetamol was given. At the child's request her special calorie and protein- rich diet was stopped. On this day, her mother left on top of the oxygen tent the sadly inappropriate gift of a painting book. The next day the child died. Her parents were not present. Throughout her illness they had made a few short visits, and they had somehow eluded an interview with the medical staff. Child 2 Other children in this girl's family were affected by cystic fibrosis. She had a history of recurrent chest infections and diarrhoea, and was seven years old at the time of her admission. Her recent history and clinical findings were similar to those in case 1. On admission, active treatment was started with humidified oxygen, intrave- nous fluids and antibiotics, bronchodila- tors and mucolytics, sodium cromogly- cate, and physiotherapy. Occasional epi- sodes of chest pain, dyspnoea (difficulty with breathing), and panic after cough- ing were controlled with paracetamol and the relaxant diazepam regularly by day. On the 11th day, clinical improvement began and the intravenous fluid drip came down. She was mobilized and was beginning to enjoy toys, television, and friends on the ward when she had to go into isolation with an intestinal infection on day 15. Her condition remained static for the next seven days, but she could not go home because of the risk to younger sisters and brothers of gut infection. On the 23rd day she relapsed with severe dyspnoea and cyanosis, again needing oxygen, intravenous fluids, and a change of antibiotics. So far, recovery had been hoped for, but it was now realized that this was likely to be her final illness. Her parents had maintained close contact with their child and with the medical and nursing teams, and they gradually began to accept that the aim was no longer cure but comfort. The isolation cubicle had the advan- tage of privacy, allowing quiet conversa- tion, personalized television, or music. With the ward staff's understanding, a simple service of prayer was held there on the 34th day of her admission. Al- though clearly aware of the implications, she as always displayed remarkable ex- citement and confidence about "going to heaven", without any discernible fear of death. Her parents had clearly supported her well and this day was evidently one when the whole family found a degree of consolation. After this, all drugs and diet unrelated to controlling her symptoms were stopped, as was aggressive physiothera- py. At the onset of distressing dyspnoea, a continuous infusion of diazepam was started, the dose being titrated (regulat- ed) according to the symptoms until agi- tation stopped. Given round the clock, the drug helped the child to ignore dys- pnoea by day and allowed sound sleep at night. On the 45th day distress recurred. A random injection of intramuscular Dying children need help too by Jennifer A. Chapman and Janet Goodall 16 The lives of these very sick children were saved, thanks to effective treatment and loving nursing care. As this article points out, even in childhood it is important to treat the whole person and to see the child in the context of the family. (Photos WHO/ Y. Pouliquen and WHO/P. A. Pittet) papaveretum hurt and upset her and it was agreed to use oral or intravenous drugs only. The next day her condition remained cheerful and chatty (she was still on diazepam) despite severe dys- pnoea. On the 47th day the drip was removed so that her parents could hold her. Syrup of diamorphine with cocaine was substituted in six-hourly doses throughout the night and into the next day, and she became semiconscious. Suddenly she struggled out of bed, smiled happily, and hugged each parent in turn before dying quietly in her fa- ther's arms. Discussion These two cases show that illness can cause physical, emotional, and spiritual pain to family and staff. In retrospect, these areas of distress were not clearly defined in either case and opportunities to alleviate suffering were missed. The first child received virtually no sympto- matic relief, and the remembrance of her last days was still painful to the nurses three years later. This hindsight helped to inspire more determined efforts to help the second child. The omissions in care were partly due to constantly changing medical staff, who also failed to register observations made in the nursing notes. These ade- quately described both children's feelings but may never have been read by a doc- tor and were clearly not communicated properly. The failure hinged on the fact that neither nurses nor doctors realized their own potential for relieving symp- toms. Physical pain: Both children ex- perienced dyspnoea and attacks of coughing with chest pain. Even though it was not immediately realized that the first child was dying, symptom relief should have been thought of. She actual- ly received only one dose of paracetamol. In case 2, however, there was a definite attempt to titrate treatment against symptoms using mucolytic and broncho- dilator agents and regular analgesics. Emotional pain: We are not aware how much emotional pain the first child suf- fered. The second experienced fear, im- prisonment by her oxygen tent, dislike of diet, and insomnia. Her fear was alleviat- ed by the willingness of both her parents and the staff to talk openly with her, by diversional activities, and by anxiety-dis- pelling agents. Finally, all treatment was stopped except that needed for control- ling her symptoms. Spiritual pain: We have found that many families suffer in spirit during a terminal illness and some turn desperate- ly to faith healers. Such people need un- derstanding, not criticism. In case 2, the parents each had an active Christian faith, which clearly saved them from overwhelming fear and despair. Speak- ing of their child's last moments, her parents could later say, "This was not passing from life into death, but from death into life." Their experience may comfort others. Family and staff pain: In the first case we can only guess at how much her fami- ly suffered : we know that the staff had painful memories. The parents and sis- ters of case 2 received much help, and with the caring staff had mutual support. This has continued in bereavement fol- low-up. The principles of controlling symp- toms need to be remembered as much during distressing treatment as during the distress of dying. There are, however, few published guidelines for use in child- hood. Children suffering from renal fai- lure, respiratory failure, and malignant disorders will need such help at intervals throughout their illness—from the initial biopsies, during radiotherapy and chemotherapy, to the end. We already know that diazepam does not suit all children and are now doubtful whether cocaine should be used at all. Studies are needed on the value of antiemetics (agents preventing vomiting), on the reg- ular giving of oral opiates, and on the metabolism and interaction of drugs in childhood. We believe that these prob- lems are often encountered in the major treatment centres and that the experience gained in such management needs to be pooled and shared. Just as important, we also need to know whether such regimens could be managed in the home. Even in childhood it is important to treat the whole person and also to see the child in the context of the family. Only by thinking in these terms shall we learn what can be done to help all members of the family to come to terms with their loss. ■ This article is reprinted by permission of the authors and the British Medical Journal. 17 Medical ethics: a viewpoint from the developing world To help, to heal, to comfort, to act with compassion—all these bear testimony to the moral consciousness of doctors. Whatever new strains are imposed upon medical ethics, this structure will continue to guide their professional conduct by J. S. Neki he idea of the human respons- ibility of the doctor must have been present even in an age when medicine was indis- tinguishable from magic. Even in Vedic times, some 5,000 years ago, when medi- cine and magic had not completely part- ed company, a physician was required to follow an ethical code : "Thou shouldst be free from impatience and always attentive, doing everything with a mind centred upon thy work— behaving with humility and acting after reflection thou shouldst with thy whole heart strive to bring about the cure of those that are ill—not for thy life's sake extorting their substance. Thou shouldst not even in imagination, know another man's wife, and similarly thou shouldst not appropriate the possession of others." The formal codes of medical ethics of the earliest times, whether of Hammura- bi (2000 BC) or Susruta (5th century BC) or Hippocrates (about 460-370 BC), all revolved around the doctor-patient rela- tionship. Even within this two-sided situ- ation, the responsibility which the com- munity chooses to vest in the doctor det- ermines the pattern of his responsive- ness. However, it appears that the influence of modern health care now spills far out- side the consulting room, and medical ethics has ceased to be an affair of physi- cians alone. Recent medical progress has brought in its wake an increasing realiza- tion that ethical problems are the concern not only of the practising doc- tors, but of the whole community. Ministering to the needs of the sick has traditionally been the doctor's duty. But what, at one time, was a simple ethical dictum has now become an ethical dilem- ma. Should a community contribute its resources for the treatment of all the ill- nesses its members may suffer from or should it, out of economic expediency, give priority to some over others? The practice of community health care has brought into focus the question of priori- ties of health care. Where medical man- power is scanty, especially in the deve- loping world, the major ethical issue has become : "Shall we promote availability of the most advanced medical care for the selected few, or provide primary health care to the multitudes?" Recent advances in medical science, particularly those that have made artifi- cial organ substitutes and tissue trans- plants possible, have brought in their train new moral conflicts. These proced- ures are, today, the pinnacles of prog- ress of modern medicine; but their ex- pensiveness makes them lie outside the reach of the common man—more partic- ularly in a poor developing country. They have thus increased the distance be- tween the common man and the best available treatment procedures in mod- ern medicine. The questions today are : must the availability of best medical care depend upon the purchasing power of the patient? And what should the medi- cal profession accept as its primary res- ponsibility—to salvage further territo- ries from the hands of mortality, or to provide primary health care to the multi- tudes? These are new ethical paradoxes that confront the medical profession the world over—but torment the conscience of those in the developing countries. Mortality or morbidity Another dilemma that the profession faces, particularly in the overpopulated developing world, is this : Should physi- cians' primary concern be with mortality or with morbidity? Concern with the former would impel them to give priority to diseases with a high mortality rate. However, mortality cannot be excluded, it can only be postponed. That improves longevity, and in the process the popula- tion is increased. An enhanced span of life also yields new patterns of morbid- ity—degenerative disorders taking the place of infections, for example. One is tempted to ask : does the balance event- ually stand in favour of mankind? If the emphasis were to be reversed and the profession were to give primary concern to morbidity in preference to mortality, this would focus medical at- tention on those conditions which cause more prolonged and profound distress to mankind. Chronic illness which is now given a deferred priority would have to be given more urgent attention. Mental illness, being not so lethal, is now a mat- ter of low priority in the context of pro- viding health care. However, since psy- Despite the prolonged distress it causes, men- tal illness still rates only a low priority in the context of providing health. Ought the medical profession to give primary concern to morbid- ity rather than to mortality? (Photo Thierry Dallant c ) 18

4 A comn u health worker immunizing a baby, and trained Ayurvedic practitioners treating a girl with rheumatoid arthritis. Med- ical ethics today has ceased to be a matter for physicians alone, but is rather the concern of the whole community. (Photos WHO/ A. S. Kochar) chiatric disorder, by and large, causes prolonged distress to patients who suffer from it and tremendous hardship to those who attend upon them, it would have to be given a high priority if mor- bidity and distress were to determine priorities. The profession's current concern with mortality in preference to morbidity is perhaps tied to the Judaeo- Christian philosophy of life and attitude towards death. Where these basic philos- ophies and attitudes do not prevail, alter- native ethical viewpoints may legitimate- ly sprout. Another area in which a reversal of current priorities and emphasis seems to be called for in certain developing coun- tries is that of rehabilitation. In the devel- oped world, where manpower is scanty, work is in abundance, unemployment is slight, and the need to earn one's own living is almost a must for everyone, rehabilitation programmes ought to be accorded a high priority. But in poorer countries where unemployment is ram- pant and hordes of able-bodied, able- minded individuals are already queueing up for employment, and where depen- dence on other family members is not considered dishonourable, rehabilitation programmes can perhaps be relegated to a lower priority. Medical procedures Human experimentation is in no sense a recent venture. A Persian prince during Avicenna's days—around 1000 AD—is known to have advised a young man who was about to join the medical profession thus: "Once you embark on a career as a physician, if you wish to gain experience and a reputation you must experiment freely, but you had better not choose people of high rank or political import- ance for your subjects." As in the days of Avicenna, the selec- tion of subjects for medical experiments today continues to be a vexing ethical problem. First and foremost is the prob- lem of "free and informed consent" of the volunteers. In many developing countries, where the ethos of an indus- trial community and of a hyperspec- ialized medical profession has not yet taken root, the doctor-patient relation- ship still closely approximates to the con- ventional one. Patients have a strong dependency relationship with the treat- ing physicians and find themselves in a debt of gratitude to them. So they suc- cumb more easily to giving formal con- sent for research procedures. How far can such consent be considered free? Likewise, where hordes of patients are either illiterate or poorly educated, how far is informed consent possible? I am reminded of several patients in India whom I wanted to take up as sub- jects in one or another of our research in- vestigations. I fully explained to them the purpose and procedure of the particular research project, their expected role in it, and the possible adverse effects that could accrue to them during the research. Then I asked them if they would be willing to participate in the research. The answer in all those cases was : "Doctor, you know the best. When you are there and if you want me to par- ticipate, there is no reason why I should not !" The question is : Should this be considered as appropriate consent and should the patient therefore be included in the research; or should this be consid- ered as inappropriate? It appears that our community still hasn't developed the legalistic consciousness of personal rights and is still prepared to function through faith. It is all the more impor- tant for doctors practising in such com- munities to exercise the utmost discre- tion, and to involve a patient in research only in cases where they would be pre- pared to involve their own kith and kin. Where patients depend on the doctors' benevolence, the latter must studiously 21

Left: In a healthy community, all members of the family contribute their labour. It follows that both ethical and medical problems are now recognised as the concern, not only of the prac- tising doctors, but of the whole community. (Photo WHO/E. Schwab) Above: Advanced medical care for the select- ed wealthy few, or primary health care for the impoverished multitudes? This picture surely proves that there can be only one answer. (Photo Thierry Dallant ©) avoid situations where exploitation can be even remotely suspected. I feel inclined to draw a distinction here between medical ethics in the con- text of "faith" and in the context of "rights". The former is based on the pri- mary premises of humanity and good- ness. Under its aegis, ready forgiveness is granted to the doctor if any harm he or she has caused is believed to have oc- curred inadvertently. It also obliges the doctor to remain consciously benevolent and refrain from exploiting his patients in any way for his own personal advance- ment. Legalistic ethics, on the other hand, rests on the basic premise of legal rights. It permits claims of compensation to be made even for inadvertent harm caused to the patient. It also makes it obligatory for the doctor to fulfil all the legal for- malities for his defence whenever he even remotely apprehends that some harmful side-effects might accrue from the proced- ures employed by him. The former can be considered to be ethics based on trust, the latter may be thought of as ethics based on suspicion. General ethical principles Behind medical ethics must stand such cardinal virtues as wisdom, justice, tem- perance, courage and benevolence. In other words, medical ethics has its locus standi only in the setting of general eth- ical principles to which it cannot run counter. The moral consciousness of medical men may be differently constituted even in one country, or under a single creed. Within the Christian faith, for example, there have been differing ethical view- points on such subjects as contraception and medical termination of pregnancy. This assumes more formidable dimen- sions if conflicting beliefs are held by people of a variety of religious denomi- nations, since on matters of faith there is little room for effective dispute. At the most or at the least, one can hope to un- derstand other people's viewpoints. However, this brings home one truism: medical ethics will differ, from place to place or from community to community, to the same degree that general ethical beliefs vary, and will share common ground to the same degree that general ethical principles share common ground. A horde of new problems For centuries, medicine hardly ad- vanced beyond the stage of folklore. The comparative suddenness with which the advent of modern science has trans- formed this ancient professional art is a remarkable phenomenon. Traditional medical ethics is already proving rather narrow for the horde of new ethical problems released by this phenomenon. A purely juridical approach gives a false and one-sided impression of the meaning of our ethical codes. To help, to heal, to reconstruct, to comfort—and all along the line to act with compassion—all these bear testimony to the moral con- sciousness of the doctor. Whatever the new strains imposed upon medical eth- ics, this structure will survive and conti- nue to guide doctors in their professional conduct. Doctors are human beings. They also have human appetites, ambitions and in- firmities. However, when a doctor enters the sick room of a gravely ill patient, the latter endows him with divine or near- divine powers. The medical man or woman has, in the eyes of the patient, powers over life and death. This exposes the doctor to the temptation of consider- ing himself above other men; to fall into the sin of self-glorification. Against this, doctors need to guard themselves studiously wherever they may belong— to the developed world or to the develop- ing one. Legal and juridical obligations they have, of necessity, to fulfil. But these are not genuine ethics. Genuine ethics has to be ingrained into character and does not have to depend upon external controls. ■ 23 "I swear by Apollo..." by Christiane Viedma he Hippocratic Oath opens with an in- vocation to the Doctor-God who is also the God of Light. It goes on to invoke Aesculapius, the son of Apollo and himself the God of Medicine, who is said to have so perfected his art that he could bring the dead back to life. This talent eventually incurred the wrath of Zeus. The King of the Gods, jealous of the power which Aesculapius could derive from such a gift, struck him down with a thunderbolt. These ancient invocations preface the Hippocratic ideal of medicine, which is: to care for one's fellow-man with the help of scientific skill, and to fend off death even when death must seem inevitable and even at the risk of upsetting the established power. After extensive travels through Greece and Asia Minor, Hippocrates is said to have settled on the island of Cos, close to the western seaboard of Turkey. There he built up a school whose teachings have so long endured that to this day medical congresses are still regularly held on Cos. The end of the fifth century B.C. and the start of the next century marked the birth of Greek philo- sophy, that striving of mankind to break away from the world of the supernatural and to explain the mysteries of life by the force of reason alone. Not surprisingly therefore Hippocrates is known as the initiator of clinical observation and as the creator of a medical theory which even though it was based on those imaginary entities, the humours— led him to the sensible and logical practice of the art of healing. This theory was to dominate medical thinking for century upon century : even in mediaeval Europe, physicians still used it as the basis of their diagnosis. Today that theory has little more than historic value, but the ideas of Hippo- crates still underlie the modern-day concept of medical ethics. What he taught about the duties of the doctor has universal value and spans all ages and cultures. Other codes of conduct and other oaths existed before him, and oth- ers have followed, no less noteworthy as statements of ideal principles. Hindu doctors, for instance, were taking an oath 1500 years before Christ, and Jewish physicians had their own oath in the sixth century AD. 24 25 1,1eit4e.:4 -N. , - '...',- .,,,. • :44 ,,.."-1.":.• ',..' The name of Asklepeion, on the island of Cos, reflects this site's ancient links with Aescula- pius, god of medicine. (Photo Greek National Tourism Office) Inset: Hippocrates, the doctor-philosopher of Cos. (Photo WHO) But it was the Hippocratic Oath that inspired the many forms of medical oaths sworn by doctors today at the moment when they enter their chosen profession, and these declarations now reflect the new attitudes resulting from the advance of science. The main princi- ples that Hippocrates laid down were : absolute respect for the sick, and the insistence that all treatments recom- mended should be for the benefit of the patient and should not be "deleterious and mischievous"; respect for human life : the physician must give no deadly medicine to anyone nor procure for a woman the means to produce abortion; respect for the medical profession : the physician must live a life of "purity and holiness"; respect for the patient's private life : the physician will enter houses only "for the benefit of the sick" and will "abstain from every voluntary act of mischief and corruption and, further, from seduction of females or males, of freemen or slaves"; respect for secrecy: the physician undertakes not to divulge any confidence that may be made, whether in the course of professional practice or otherwise. After the Second World War, when it emerged that certain doctors had partici- pated in wholesale crimes against humanity, the medical profession felt the need to reaffirm the principles of the Hippocratic Oath. One of the first mea- sures taken by the World Medical Asso- ciation on its creation in 1947 was to try to reunify the entire profession in a single global confederacy and to draw up a modern version of the Oath. The result was the formulation in 1948 of the Declaration of Geneva, followed a year later by the International Code of Medical Ethics. The Geneva Declara- tion, intended to be sworn when a doctor was admitted as a member of the medical profession, reads as follows : "I solemnly pledge myself to conse- crate my life to the service of humanity; I will give to my teachers the respect and gratitude which is their due; I will practise my profession with con- science and dignity; The health of my patient will be my first consideration; I will respect the secrets which are con- fided in me, even after the patient has died; I will maintain by all the means in my power the honour and the noble tradi- tions of the medical profession; My colleagues will be my brothers; I will not permit considerations of reli- gion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from the time of conception; even under threat, I will not use my med- ical knowledge contrary to the laws of humanity. I make these promises solemnly, freely and upon my honour." The International Code is more compre- hensive and falls into three sections : Duties of Doctors in General A DOCTOR MUST always maintain the highest standards of professional con- duct. A DOCTOR MUST practise his profession uninfluenced by motives of profit. THE FOLLOWING PRACTICES are deemed unethical: Any self-advertisement except such as is expressly authorized by the national code of medical ethics. Collaboration in any form of medical service in which the doctor does not have professional independence. Receiving any money in connection with services rendered to a patient other than a proper professional fee, even with the knowledge of the patient. 26 "I swear by Apollo..." The Declaration of Geneva 1948 Left: "1 solemnly pledge myself to consecrate my life to the service of humanity... The health of my patient will be my first considera, (Photo WHO/P. Almasy) Right: "I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. - (Photo WHO/M. Jacot) ANY ACT OR ADVICE which could weaken physical or mental resistance of a human being may be used only in his interest. A DOCTOR IS ADVISED to use great cau- tion in divulging discoveries or new techniques of treatment. A DOCTOR SHOULD certify or testify only to that which he has personally veri- fied. Duties of Doctors to the Sick A DOCTOR MUST always bear in mind the obligation of preserving human life. A DOCTOR OWES to his patient complete loyalty and all the resources of his science. Whenever an examination or treatment is beyond his capacity he should summon another doctor who has the necessary ability. A DOCTOR SHALL preserve absolute secrecy on all he knows about his patient because of the confidence en- trusted in him. A DOCTOR MUST give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care. Duties of Doctors to Each Other A DOCTOR OUGHT to behave to his col- leagues as he would have them behave to him. A DOCTOR MUST NOT entice patients from his colleagues. A DOCTOR MUST OBSERVE the principles of "The Declaration of Geneva" ap- proved by the World Medical Associa- tion. Today, these ideas again need to be filled out or adapted to keep pace with developments in science and society. Various declarations have followed each other, establishing set principles in cer- tain sectors where ethical practice needed to be clearly defined. Thus in 1964 the Declaration of Helsin- ki laid down recommendations for doc- tors who have to use human subjects for research, whether of a therapeutic nature or not. Dr J. S. Neki explains the com- plexity of this problem in his article on another page. The Declaration of Sydney in 1968 dealt with the delicate issue of determin- ing the precise moment of death, which has two particular applications. Firstly, should euthanasia be practised, in the sense of the term that is accepted today, by ceasing to maintain life artificially and through mechanical techniques in a patient in whom one vital organ, such as the brain, is irreversibly damaged? 27 Secondly, in the case of organ tran- splants, how can one be absolutely cer- tain that an organ donor is truly dead at the moment when some equally vital or- gan such as the heart or kidney is removed? The Declaration of Oslo in 1970 tackled the problem of therapeutic abor- tion, that is, when it is essential in order to save the mother's life. The question of abortion is the one which most directly conflicts with both the ancient Hippo- cratic Oath and the modern-day Dec- laration of Geneva. Some countries, par- ticularly those faced with a very rapid demographic growth, include abortion among the contraceptive means available to women. In others, this step has met staunch opposition. This is a case where the collective interest may be seen as overriding the interest of the individ- ual—that is to say, of the child conceived but not yet born. Many countries have now adopted laws permitting the inter- ruption of pregnancy in certain circum- stances. And so in France, for instance, since the adoption of such a law in 1975, the Oath taken by doctors has today only historical rather than legal value. In 1975, the World Medical Associa- tion adopted the Declaration of Tokyo which laid down guidelines for doctors regarding "torture and other cruel, inhu- man or degrading treatment or punish- ment in relation to detention and impri- sonment". This is a highly complex problem which covers such aspects as mentally disordered offenders, drug-dependent persons, corporal punishment, restricted diets, solitary confinement, various forms of restraint, electroconvulsion therapy, psychosurgery, castration of recidivist sexual offenders, intensive in- terrogation methods, and biomedical ex- periments on prisoners. WHO itself produced a report on these issues in 1975 (Health aspects of avoid- able maltreatment of prisoners and detainees), with the reservation that, as an intergovernmental organization, it was not directly concerned with medical ethics in the sense of rules of professional relationships with patients and between members of a health profession, but rather with "health ethics". This term was defined as referring to "the right of all peoples, including prisoners and detainees, to be spared avoidable hazards to physical or mental health and to have access to the best facilities for medical care that it is feasible to pro- vide". "I swear by Apollo... Left : Mental patients recovering from electro-con- vulsion therapy at a hospital in the Caribbean. A WHO report in 1975 underlined "the right of all peoples, including prisoners and detainees, to be spared avoidable hazards to physical or mental health." (Photo WHO/T. Harding) Right : Traditional midwives run their own re-training courses beside their delivery but in West Afri- ca. In an age when increasing responsibility is being placed on the shoulders of non-medical professionals, it is vital for them to be fully aware of the ethical guidelines of their calling. (Photo WHO/UNICEF/J. Ling) CASE CrACCOUCHEMENT The Council for International Organ- izations of Medical Sciences (ooms), which traditionally deals with human rights in the context of health, laid down a set of principles which were pre- sented at the 61st session of WHO's Ex- ecutive Board last year. It was suggested at the time that, while these principles applied essentially to physicians, they were no less appropriate to the activities of other health personnel. Now at last it is possible to speak of "health ethics" in an age when increasing responsibility is being placed on the shoulders of non-medical professionals, health auxiliaries and rural health agents. It may reasonably be asked whether all these vital health workers are fully aware of the ethical guidelines of their calling. According to data compiled by WHO about the training programmes run by schools for medical assistants in all parts of the world, some 20 per cent of the trainees—that is, people with eight or nine years of general education and two to three years of technical training—have had a course in medical ethics included among their other subjects. The same percentage of dental auxiliaries have also . undergone such courses in respect of their profession, while 13 per cent of laboratory technicians have had to familiarize themselves with matters of principle. But what about the village health worker, who may only receive formal training for a matter of a few weeks? An experimental WHO handbook prepared for the primary health worker has this to say on the subject: the agent's mission consists of promoting community devel- opment activities and playing an active role in these activities; he or she should therefore be available at all hours of the day or night to respond to emergency calls, and should in all circumstances react with common sense, devotion to duty and awareness of his or her limita- tions and responsibilities. Here we have the starting-point for a code of ethics. Health agents who so often devote every effort to the well-being of fellow-members of the community have every right to embrace as their own the words which open the preamble to the Declaration of Tokyo : "It is the pri- vilege of the medical doctor to practise medicine in the service of humanity, to preserve and restore bodily and mental health without distinction as to persons, to comfort and to ease the sufferings of his or her patients." ■ 000 0 00 00 0 00. 000 1100 00 0 000 000 000 000000 00• 000 000 000 ••• 4, 11, :::••• ••• ••• 000 000 0041 00 0 000 000 000 4100 0 00 000 00. 000 1110411 410. *00 4100 41 00 00 0 00* 000 0000 00 *00 000 000 000 4100 000 000000 000 000 000 0410 000 4100 000 000 0041 0410 000 Self-reliance seen as main TCDC goal The essential objective of technical cooperation among developing countries (TCDC) is the development of na- tional and collective self - reliance. This view was ex- pressed by a Technical Dis- cussions group convened on the occasion of the Thirty- second World Health Assem- bly last May. This was the third major international gathering within 9 months at which TCDC re- ceived top billing. At the UN Conference on TCDC held in Buenos Aires in August- September last year, the con- cept was evaluated and ac- cepted as a vital force to promote cooperation among developing countries. In Sep- tember, the Conference on Primary Health Care held in Alma-Ata underlined the im- portance of TCDC in the struggle for better health. Technical Discussions, de- voted each year to a specific subject in international health, are a regular feature of the Health Assembly's annual sessions. Many Assembly de- legates take part in the dis- cussions in their individual capacity, along with other experts. There were 348 par- ticipants in this year's discus- sions devoted to "Technical cooperation in the field of health among developing countries". The group recommended that each Member country should establish a focal point to facilitate and coordinate TCDC activities and to act as the contact point with other countries. Governments should have a clear policy for TCDC, and cooperation in the health sector should be based on a national health programme. The creation of national information systems with a built-in mechanism for in- formation exchange with other developing countries was considered essential. In this context, WHO was asked to review its existing informa- tion services and to make available to the countries in- formation in its data bank on resources in the countries on health manpower, health training and research. The group felt that na- tional programmes to train educators and research work- ers could ideally be under- taken as cooperative activi- ties with other countries. Developing countries should assess and make known their priority needs in training of health workers, including teaching staff; the type of assistance they could use immediately; and the facili- ties and teaching staff they were willing to make avail- able for cooperative pro- grammes. The manufacture and qua- lity control of essential drugs was identified as a pro- mising area for successful TCDC programmes. WHO was asked to assist by or- ganizing group meetings of interested countries to con- sider cooperative projects and joint ventures in the production, procurement and distribution of essential drugs, medical supplies and labora- tory equipment. Poison fish abound in French Polynesia A WHO consultant has warned against eating liver of any fish caught in the seas around French Polynesia in the South Pacific. He said that liver of fish in that area can be poisonous even when the fish is non-toxic (not poisonous). Dr Takeshi Yasumoto, WHO consultant, also de- clared that the spotted (black) grouper, the red grouper and the snapper fish caught in French Poly- nesian waters have been found to be highly poiso- nous. He advised against the sale and consumption of these fish weighing over 1.2 kilograms. "It is advisable to eliminate the viscera (intestine, liver) before the fish are brought to the market", Dr Yasumoto said. He stated that the bigger fish are more poisonous than the smaller ones. Nearly 800 cases of fish poisoning are reported offi- cially every year in French Polynesia. However, the ac- tual number may be much higher as many cases of. fish poisoning occurring in re- mote islands are not reported to health authorities. Photo WHO/D. Deriaz "The bigger the fish, the greater the risk." At the request of the Go- vernment, WHO sent Dr Yasumoto to French Poly- nesia late last year to do an ecological survey and to find a way of testing fish sold commercially in the market- place of Tahiti. During this assignment, Dr Yasumoto demonstrated that it was possible to determine whether a large number of fish are poisonous by testing the livers of a few samples selected at random. The source of this poison in fish is a one-celled or- ganism called dinoflagellate which attaches to algae growing in coral reefs (see World Health, June 1977). Small fish feed on the algae which carry the dinoflagel- lates. These small fishes are, in turn, eaten by the bigger ones. The toxin is then trans- ferred and concentrated as it moves further along the fish food chain. The bigger the fish, the more potentially toxic it is. Human beings are extremely sensitive to this toxin; less than a milli- gram can be lethal to an adult. The dinoflagellates present in coral reefs seem to be provoked to multiply when their environment is dis- turbed. Man himself may cause this disturbance when blasting off reefs to build a runway, wharf or pier. Dr Yasumoto says there are several known examples where human aggression against coral reefs seems to have triggered explosive out- breaks of the fish poisoning phenomenon known 'as ci- guatera (a word of West Indies origin). The toxic dinoflagellate when first identified was ten- tatively assigned to genus Diplopsalis. However, Dr Ya- sumoto says that a subse- quent study revealed that this organism belongs to a new genus and new species and it was then given a new name, Gambierdiscus toxicus. Another important aspect of the research work on fish poisoning is the study to develop treatment proce- dures for poisoning victims. Experiments are also going on to produce an antigen— a substance which when injected will help the hu- man body to neutralize the poison. Dr Yasumoto says that various research activities are being carried out at the Ins- titut de Recherche nnedicale "Louis Malarde" (IRMLM) in Papeete, capital of Tahiti, one of the Polynesian group of islands. Since poisoning is a worldwide phenomenon, the results will be of global importance, Dr Yasumoto says, recommending financial support, from both local and international sources, for the activities of the IRMLM. 30 Ft. Cholera patient. Photo WHO/D. Henrioud '78 cholera cases show rising trend Cholera cases in 1978 totalled 74,632 as compared to 58,087 in 1977, according to information compiled at WHO headquarters. The dis- ease was also more wide- spread, with 40 countries sending in reports. This num- ber is the highest ever re- corded since the beginning of the present pandemic in 1961. Only once before—in 1974 did the disease strike in 40 countries. Eight new countries were infected in 1978: Burundi, Congo, Rwanda, Zaire and Zambia in Africa, the Maldives in South-East Asia, Nauru in the Western Pacific, and the USA. Eighteen countries in Africa reported a total of 23,317 cases as compared with 12 countries reporting 8,388 cases in 1977. Nearly two- thirds of the cases were from Burundi and Tanzania, where large outbreaks oc- curred. Ten of these 18 coun- tries had not reported cholera in 1977. A significant de- crease in the number of cases as compared to those in 1977 was noted in Ghana, Liberia, Malawi and Togo. In Asia, a total of 50,765 cases (including 22 imported cases) were reported by 19 countries. Five of the countries had not reported cholera in 1977. A large outbreak involving 11,336 cases in the Maldives was rapidly brought under con- trol by measures including purification of drinking water and careful epidemiological surveillance of cases. In Bahrain, the disease ap- peared for the first time since 1973 in a large outbreak with 906 cases. This outbreak was unique in that the highest attack rate was in children below one year of age, es- pecially those who were bottle-fed. A small outbreak occurred in the USA—the first in the continental United States during the present pandemic. The 12 cases reported were associated with consumption of steamed or boiled crab. In Oceania, cholera spread to yet another country, Nauru, where 38 cases were re- corded. At least in one country, it was demonstrated that the requirement of cholera vac- cination certificates from travellers entering the country failed to prevent the in- troduction of cholera. It may well be that this measure breeds a false sense of se- curity. While the disease is thought to be barred at the point of entry, it may be taking root in the community and, in the absence of -sur- veillance measures, become widespread before it is de- tected. It is worth inves- tigating whether the health staff ritualistically checking cholera certificates at entry points would be better uti- lized if employed in even the most elementary form of diarrhoeal disease surveil- lance. Smoking threat to developing world Unless they act quickly, the developing countries can expect within 10-20 years a heavy burden of cigarette- related diseases, the WHO Expert Committee on Smok- ing Control has warned. Cigarette consumption in these countries is increasing as the powerful international companies turn their atten- tion to new markets in the third world, unfettered by legislation or controls. The third world consumer, often uninformed about the risks of tobacco, smokes a more dangerous cigarette: a plain cigarette with twice the amount of tar permitted in many developed countries. Tobacco is a source of substantial revenue for many countries, both developed and developing, and many governments are reluctant to change their policy. How- ever, in developed countries it is already clear that the gains are far outweighed by the socio-economic cost of cigarette-related diseases in cluding lung cancer, and cardiovascular and respira- tory illnesses. In the next issue While it is generally agreed that our planet can produce enough food for all its hu- man inhabitants, that food is neither fairly distributed nor sensibly chosen. The August- September double issue of World Health will look at various aspects of nutrition in the world today. Authors of the month Dr T.A. LAMBO is the Deputy Director-General of the World Health Organization and former Vice-Chancellor of the University of lbadan, Nigeria. Mrs H. SIPILA is the United Na- tions Assistant Secretary-General for Social Development and Hu- manitarian Affairs. Dr W. L. BARTON is the Pro- gramme Manager of Staff Devel- opment and Training at WHO head- quarters in Geneva. Dr J. A. CHAPMAN is the Senior Registrar at St. Christopher's Hos- pice, London, and Dr J. GOODALL is Consultant Paediatrician at the North Staffordshire Hospital Cen- tre, Stoke-on-Trent, England. Professor J. S. Nun is the Director of the Postgraduate Institute of Medical Education and Research in Chandigarh, India. Mrs C. VIEDMA is the Deputy Ed for of World Health. WORLD HEALTH ORDER FORM Please enter my subscription to "World Health" as follows: One year Two years Three years US$ . 12.50 22.50 30.— Sw.fr.* 25.- 45.- 60.— One year: Two years: Three years: 0 I enclose cheque/postal order in the amount of Name: Street: City: Country: * or equivalent in local currency . World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland te d in S w itz er la n d Ir ne rim er ie s R eu ni es S .A . La u sa n ne Women, health and human rights. See article by Helvi Sipi'a on page 6. (Photo L. Solmssen, League of R9d Cross Societies)