On December 22, New Zealand and Belgium became the 25^th and 26^th nations to ratify the Convention on Cluster Munitions (CCM). The convention needs only four more ratifications to achieve the 30-state minimum to enter into force. Once in force, it will enact a ban on the use, stockpiling, production, and transfer of most cluster munitions, which include bombs, missiles, or rockets that open midair to scatter tens to thousands of small submunitions over a wide area. The CCM also requires that states destroy their stockpiles in eight years, clear contaminated land within ten years, and provide victim assistance.

This convention is necessary due to the wide, indiscriminate, and persistent effects of cluster munitions on civilians and communities. Ninety-eight percent of all recorded casualties of cluster munitions are civilians. In several countries, children account for roughly 60% percent of the victims. In 2007 alone, 5,426 casualties were reported due to cluster munitions. Conservative estimates suggest that unexploded submunitions have caused at least 55,000 casualties, though the number may be well over 100,000.

Victims of cluster munitions require medical, mental health, rehabilitation, and vocational services. They sustain burns and blast and shrapnel injuries, often to multiple limbs as well as their chest, abdomen, and face. Victims should also receive rehabilitation services, including mental health care, physical therapy, and prostheses if needed. Many of these services are unavailable or scarce in conflict zones, and the added burden of these patients can overwhelm an already strained health system, especially in post-conflict settings.

Victims of cluster munitions also need assistance with integration back into society. In many affected areas, people living with disabilities face stigmatization, marginalization, and a lack of economic opportunity. Efforts to promote the rights of the disabled — such as those spearheaded by Handicap International — are essential to any long-term approach to addressing the effects of cluster munitions.

Though cluster munitions are often compared to landmines in that they both litter areas after a conflict is over and pose a threat to the health and human rights of individuals and communities, there are notable differences in their effects. Cluster munitions are more likely than landmines to cause multiple injuries per incident, and they are more likely to kill or injure children under the age of 14 due to their small size and bright coloration.

Unexploded cluster submunitions slow humanitarian, recovery, and resettlement efforts after overt hostilities have ended. Humanitarian and relief workers may be unable to enter an area due to cluster munition contamination. In Kosovo, Laos, Vietnam, Afghanistan, and Lebanon, casualties peaked as populations returned home after the conflict ended. Returning populations are injured while attempting to access their houses, farms, pasture land, water supplies, and health facilities. In Afghanistan, many people have been injured by explosive remnants of war (of which cluster munitions are one form) in the past decade, and these deadly devices have deterred people from accessing health services and from sending their children to school.

The short- and long-term effects of armed conflict and political violence continue to undermine the health and human rights of populations around the world. An international ban on cluster munitions will be an important step toward protecting and promoting health and human rights and toward allowing those whose lives are ravaged by wars to farm their fields and walk the streets of their communities without fear.

Physicians for Human Rights National Conference
Health and Human Rights in 2010
Saturday, February 20^th, 2010
Boston University Medical School in Boston, Massachusetts

Register now at www.PHRStudentConference.org!

Physicians, nurses and public health specialists in the U.S. and abroad face a daunting task: building, and often rebuilding, health systems that are accessible to all; fighting infectious pandemics like HIV/AIDS; preventing and treating disease; providing humanitarian relief to people facing natural or man-made disasters; and more.

The last 20 years have shown the world that brilliant bio-medical advances cannot alone bring health to the world’s poorest people. Medicine must go hand-in-hand with human rights to eliminate health disparities and ensure a healthy population.

This year’s Conference aims to change the paradigm of medicine to one which embraces human rights by empowering student leaders to introduce human rights into their school curriculum. The Conference is the first of its kind to solely focus on bringing students and faculty together to discuss how to integrate human rights into medical education. This jam-packed day serve as a springboard for future health and human rights initiatives and support students to make lasting change at their university and in their profession.

Highlights include:

• Network with National Leaders: Renowned experts in the field of health and human rights who will share their knowledge and expertise with you.  This conference provides a rare chance to meet and network with health professionals interested in human rights from all over the US.

• Build Your Skills: A dynamic lineup of workshops, panels, and strategy sessions that will address the need to integrate human rights more completely in medical education and cover the best strategies for planning electives for credit and garnering faculty support.

• Take part in the Student Expo: An Education Expo when students who have designed courses for credit, created extracurricular activities and started clubs to further awareness will present their projects and provide advice and ideas for their peers hoping to spearhead similar initiatives.

• Change Policy: Hear from US Representative James McGovern (D-MA, Invited)—Chair of the Congressional Human Rights Caucus and health reform expert— about human rights and health reform, and ask him the tough questions about how to make sure health is recognized as a human rights in the Us and abroad.

• Join us for a Jazz Reception: Join student leaders, faculty, and PHR staff and Board members for a jazz reception Saturday evening. Enjoy music, hors d’eourves, drinks and conversation overlooking Boston’s stunning skyline.

Attendees will leave with concrete guides to follow to help further their goals on campus, and will have the opportunity to meet personally with faculty from their schools to discuss future initiatives.

Join PHR at the National Conference – a unique opportunity for passionate health professional students and faculty to come together for a remarkable day to harness their knowledge for health and human rights.

Questions about the National Conference?  Email Hannah.

This is a guest post by Leah Bevis and Alison Hayward, MD for Uganda Village Project, an IFMSA transnational project. There are many ways to get involved with UVP, including through summer internships. – Sujal Parikh

Naigaga Florence lives in Bulumwaki Village, a small, extremely rural community in eastern Uganda. A thin, toothless, but smiling old woman, we first sighted her at a village outreach – in her arms was the most malnourished child that any of us had ever seen. The child’s eyes were dull, his hair a few blondish wisps on a dry skull. His tiny limbs were mere bones draped in shriveled skin, and his head lolled on his neck as if about to fall off completely. His name was Alfred, and he suffered from severe malnutrition, since his mother had died and was unable to breastfeed him. Without breastmilk’s protection, babies in the rural villages of Uganda face a grim prognosis. They are fed a thin gruel of flour and water which provides hardly any calories, or the protein they need to grow.  

For 9 thousand Ugandan shillings – about five dollars –we provided Alfred with one large cup of milk every day for a month. Naigaga scrapes together enough money to buy millet, soy, and maize porridge, and a bit of oil, to mix in with the milk after it is boiled. Alfred grew stronger, became the brown color he ought to have been, gained tiny layer of flesh over his bones. His eyes began to focus. His grandmother Naigaga showed up at every single Uganda Village Project event, greeted our staff with hugs and dancing, and thanked us profusely, over and over again, for saving her grandson’s life. Though he is infinitely more healthy than he was, Alfred’s life is still fragile – propped up, as ridiculous as it seems, by five dollars worth of milk every month.

The majority of Ugandan village children are malnourished. Almost all suffer from mild kwashiorkor, caused by protein deficiency and presenting with a distended stomach, thinning and blonding hair, edema, inadequate growth, and edema. Some suffer from iodine or iron deficiencies, many suffer from Vitamin A deficiencies (which causes a prevalence of eye problems), and the children of very poor families suffer from marasmus (protein and carbohydrate deficiency, basically starvation).Twenty percent of Ugandan children are underweight for their age, and this rate is certainly much higher in the rural villages where Uganda Village Project works.

Malnutrition in children can be deadly on its own, but more often it weakens the immune system, causing a higher incidence of malaria, typhoid, skin infections, respiratory infections, and tuberculosis. Malnourished children who escape death often suffer from reduced physical and mental capacity, and may do poorly in school or be less able to provide for their families in the future.

We are working to prevent and treat child malnutrition in a number of ways, including education, subsidized vegetable seeds for villagers, and training for planting small, water-efficient vegetable gardens. We are also providing emergency aid to severely malnourished babies like Alfred by paying for a cup of milk a day.

While Ugandan children face a variety of challenges, both in health and otherwise, malnutrition is one of the most cross-cutting and deeply rooted of these challenges. By working to prevent malnutrition in rural Iganga, we are working for a better future for the children, and a better future for their society as a whole.

The role of medical students in limiting the spread of antimicrobial resistance

Adam Castaño‡, Sujal Parikh‡ and Eunice Yu, medical students at the University of Michigan Medical School, Ann Arbor, Michigan, USA (‡ These authors contributed equally to this post). Contact Adam Castano on acastano@umich.edu.

Nowhere in the world is free from the spread of drug-resistant bacteria, parasites and viruses.  The World Health Organization (WHO) Global Alliance for Patient Safety has recognized the dual problems posed by the increasing incidence of drug-resistant bacteria and the decline in antibiotic innovation.  For the past two years, a working group of policy makers, scientists, epidemiologists, and economists have assembled at several international meetings to outline an international strategy to address antimicrobial resistance (1). Policy recommendations, to be launched in 2010, will establish new roles for governments, public health departments, industry, and physicians as primary stakeholders in AMR prevention and alleviation.  Physicians prescribe antimicrobials, contribute to the spread of pathogens (particularly hospital-acquired infections), educate patients about appropriate use of antimicrobials, perform research, and set research agendas.  Medical students are being trained in an era where the toll of antimicrobial resistant infections is evident on a daily basis.  As future physicians, they have the potential to help to address this problem.  Here, we describe new leadership roles for medical students within their medical schools, hospitals, communities, states, and countries to alleviate the problem of AMR.

The role of medical students in medical schools

Medical schools, in particular the preclinical years, offer time for extracurricular activities that could be devoted to student forums dedicated to educating peers and discussing antimicrobial resistance with faculty members from a wide variety of disciplines.  Medical students can form a student group, such as a chapter within their medical school of Antibiotic Defense , an organization of doctors, scientists, and professionals dedicated to conserving the availability and efficacy of antibiotics.  Initial meetings dedicated to discussing fact sheets and publications from experts and opinion leaders would build the knowledge base needed to understand core issues in the field.  Initiatives at the World Health Organization (2), ReAct: Action Antibiotic Resistance,(3) the Alliance for the Prudent Use of Antimicrobials,(4) and the Global Health Education Consortium (GHEC) contain useful information.  Antibiotic Defense, in conjunction with GHEC, has published an open-access online module that medical students can utilize to educate themselves about the global nature of antimicrobial resistance (5).

Once students have attained a baseline understanding of the field at the local, community, national and international level, they can help educate fellow students in health professional schools in their region.  GHEC accepts modules written by medical students designed to educate peers about issues pertaining to global health.  Medical students can also work with faculty in their medical school to identify and fix gaps in their curriculum.  Medical students should be informed of relevant international, national, and local policies affecting antimicrobial resistance, in addition to epidemiology, pathophysiology, and treatment.  It should be emphasized to medical students that they play a role in containing AMR (figure).

The role of medical students in hospitals

Medical students in hospitals – as healthcare providers and as inadvertent contributors to the spread of pathogens – play an important role in the containment of AMR.  Hospital-specific resistance trends and drug sensitivities for specific organisms can be learned from antimicrobial stewardship committee lectures and in-house publications.  Familiarity with such resources can inform accurate antimicrobial choices.  Equally important are drug resistance and sensitivity data for individual patients with culture-positive infections.  Medical students can find this data by calling the microbiology lab or contacting outside hospitals for transferred patients.  This up-to-date culture information can influence medical decision-making and ensure rational antimicrobial use.  Finally, medical students can contribute to patient safety guidelines and quality improvement efforts in addition to role-modeling infection control techniques for their patients, residents, and attendings (senior physicians).

The role of medical students in the community

In addition to promoting change in their schools and hospitals, medical students can play a key role as educators and advocates in their local communities.  The first step to fulfilling these functions is learning local patterns of AMR using resources outlined above.    Students can then educate their community by writing opinion pieces and informational articles that discuss the growing problem of antimicrobial resistance and highlight its local manifestations.  Articles specifically outlining steps for community members to limit the spread of resistance will be most applicable to community audiences.  For example, methods highlighted for a community should relate to its unique circumstances in addition to reiterating known containment methods, such as not sharing antibiotics or thoroughly cleaning shared items like gym equipment (6). Students can also determine the extent to which local public health and sanitation regulations limit the spread of antimicrobial resistance and lobby policymakers to change those statutes to protect public health.

As students engage in these processes, they will undoubtedly encounter topics where no reliable information is available.  In these cases, joining a team that researches the biological, clinical, epidemiological, social, or economic aspects of antimicrobial resistance can generate the knowledge required to engage the activities outlined throughout this article.

The role of medical students in their state and country

Medical students can also influence discourse and policy at the provincial, state and national level.  For example, In the United States, state health departments and the National Institutes of Health (NIH) offer opportunities for medical students to work to address the problem of AMR.  Internships at state health departments could be arranged in order to learn epidemiology and public health initiatives involved in AMR surveillance and containment.  At the national level, the NIH offers prestigious year-long fellowships in basic, clinical, and translational research.  Such a program can be pursued to study the latest issues and solutions in AMR (7). Medical students interested in the politics and policies related to AMR can pursue similar internships in the office of a United States Congressperson.  In addition, the collective voice of medical students can be harnessed through organizations such as the American Medical Student Association (AMSA) or American Medical Association (AMA) in support of efforts to strengthen research and development in this sector.  Similar efforts can be pursued in other countries by working with state and provincial health departments, national medical organizations, and the International Federation of Medical Student Associations.  The World Health Organization offers additional opportunities for medical student contributions both at its Switzerland headquarters and at regional offices in the United States, Denmark, the Philippines, India, the Congo, and Egypt.

A fundamental shift is needed in our attitudes to antimicrobials.  What if antimicrobial effectiveness – not just antimicrobials themselves – was viewed as a global public good, much like clean water and forests?  Antimicrobial effectiveness is a depletable resource, accessible to all but limited in quantity.  Every time someone uses an antimicrobial, the effectiveness of that drug is slightly “used up” or “lost.” This continual depletion of antimicrobial effectiveness diminishes our ability to combat life-threatening infections and practice modern medicine.  The spread of resistance by antimicrobial overuse is therefore similar to the problems we face with regard to other resources, such as carbon emission, overfishing, and the exhaustion of oil reserves.   If we view antimicrobials as a global public good, a powerful agent whose effectiveness belongs not to an individual person or institution, but to society as a whole, then innovative efforts and policies become applicable.  These realities must of course be balanced with the benefit of antibiotic use to the individual patient.

Competing interests statement: The authors are members of Antibiotic Defense, an organization founded by medical students at the University of Michigan that aims to preserve antibiotic effectiveness.

Figure : The role of medical students in limiting the spread of antimicrobial resistance

Figure : The role of medical students in limiting the spread of antimicrobial resistance

[2] Cure With Care: Understanding Antibiotic Resistance. ReAct: Action on Antibiotic Resistance: Available: http://soapimg.icecube.snowfall.se/stopresistance/cure%20with%20care[1].pdf. Accessed: 28 October 2009.

[3] Alliance for the Prudent Use of Antibiotics.  Research and Surveillance Initiatives: Available: http://www.tufts.edu/med/apua/Research/research.html .  Accessed 28 October 2009.

[4] Castaño A, Kober M, Jain A, Prensner JR, Haack S, Parikh S (2008)  “Antibiotic Resistance: Challenges and Solutions.” Global Health Education Consortium.  Available: www.globalhealthedu.org.  Accessed: 28 October 2009.

[5] Centers for Disease Control, Interagency Task Force on Antimicrobial Resistance and a Public Health Action Plan to Combat Antimicrobial Resistance. National Center for Preparedness, Detection, and Control of Infectious Diseases/Division of Healthcare Quality Promotion (2006) Available: http://www.cdc.gov/drugresistance/actionplan/index.htm.  Accessed 28 October 2009.

[6] Howard Hughes Medical Institute, Research Scholars Program. National Institutes of Health. Available: http://www.hhmi.org/cloister/.  Accessed 28 October 2009.

[7] Laxminarayan, R and Brown GM (2000) Economics of Antibiotic Resistance: A Theory of Optimal Use. Resources for the Future.  Discussion Paper 00-36.  Available: http://www.rff.org/rff/Documents/RFF-DP-00-36.pdf.  Accessed 28 October 2009.

Steven Kanter presents the series by echoing the World Health Organization’s definition of health as more than the absence of disease and noting that “peace is not simply the absence of war.”

Ali Khan and colleagues point out that “Violence, manifest in myriad forms, exists in our own backyards and clinics. Just as international conflict zones provide an entry point for physicians to rebuild health systems and societies alike, so too do low-income urban neighborhoods, the halls of Congress, and the steps of the United Nations.”

Barry Levy and Victor Sidel, veterans of organizing physicians in support of peace through the group International Physicians for the Prevention of Nuclear War, argue that the medical establishment should begin building peace at home by “(1) fostering cooperation in relationships among themselves and others, (2) preventing conflict by promoting transparency and ethical behavior, and (3) promoting mediation and arbitration to resolve conflicts before they result in serious adverse consequences.” These suggestions may seem far removed from what most of us think as preventing violence, but as peace scholars have pointed out for decades, efforts to construct and sustain peace must begin long before we reach the cultural and societal breaking point of war.

In a another essay, Hagopian and colleagues call on health and medical associations to “change the dominant framework so that failing to act against war would be the more peculiar act of health professionals, rather than the opposite.”

My favorite quote, however, is in Seiji Yamada’s essay, “Academic Medicine Should Start at Home”, in which he exhorts American academics to quantify and expose the morbidity and mortality caused by military, diplomatic, and economic actions of our own government. Yamada writes about some students, “At the mention of history or political economy, our learners groan. We are not interested in politics, they say. But unreflective learners repeat the blather that they are fed by the corporate media. Their interest in politics extends only as far as protecting physician reimbursements. But academic medicine has the responsibility to produce physicians who advocate for the cause of health – in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against.”

As health professionals, it is our responsibility to raise our voices, to count and bear witness to the deaths and injuries, to mourn with our patients and their loved ones, to oppose injustice, and ultimately, to organize a system that better builds peace.