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Editorial March 2009

The Global Female Patient

Barbara Gottlieb, MD, MPH

In December 2008, The Board on Global Health of the US Institute of Medicine (IOM) of the National Academy of Science issued a brief report on Global Health.1 This report, the first since the IOM released America’s Vital Interest in Global Health in 1997, was timed to coincide with the presidential transition, with the intention of shaping the commitment of the new administration, in its earliest days, to Global Health. A detailed report will be released in May 2009. However, the brief report calls for the United States to “live up to its humanitarian responsibilities” by promoting global health in order to improve the lives of millions around the world. The report calls for measures that will raise the profile of Global Health in the Obama administration, including a White House Interagency Committee on Global Health, chaired by a senior White House official, and a doubling of funding from the current $7.5 billion per year (2008) to $15 billion by 2012. The report specifically encourages commitment to globally recognized Millennium Development Goals adopted by member states of the United Nations in 2000, including reducing child mortality, improving maternal health, promoting reproductive health, and combating HIV/AIDS, malaria, and other diseases. Perhaps the critical message in the brief report lies in the Board’s recommendation that Global Health become a pillar of US foreign policy.

Perhaps we at The Female Patient never considered ourselves to be an integral part of US foreign policy. However, as a journal dedicated to the female patient, it is only fitting that we, too, consider our commitment to the health and well being of female patients throughout the world. Who are the female patients, globally speaking? What are their health needs? What role can this journal play in informing current and future practitioners to better meet these needs?

Recently, The New York Times reported2 that on November 12, 2008, 6 men approached the Mirwais School for Girls in Kandahar, Afghanistan, armed with assorted containers and spray bottles of acid. One man approached a 17-year-old girl and asked, “Are you going to school?” He pulled the burqa from her head and sprayed her face with acid. A total of 11 girls and 4 teachers were hit, 6 seriously enough to go to the hospital. The 17-year-old mentioned above will likely need plastic surgery to restore her disfigured face, but this is a dim fantasy for a girl who lives in a village without electricity and whose father is disabled.

Although no one has claimed responsibility for this act, the article points out that the Taliban had moved into the Mirwais area several months prior to the attack. Soon after, posters began to appear in mosques warning parents, “Don’t Let Your Daughters Go to School.”2

Further south, on the African continent, an estimated 4 million internally displaced persons reside in Sudan’s refugee camps.3 In refugee camps in Nyala Province, South Darfur, 65% to 84% of households are headed by women. A 2005 household survey revealed that while humanitarian efforts had been moderately successful in providing basic needs of food, shelter, and water, huge gaps existed in addressing general medical, reproductive, and mental health needs. Eighty-four percent of women had a history of circumcision; 51% felt that a wife must submit to sexual intercourse with her husband, regardless of her wishes; 42% of pregnancies lacked prenatal care; 53% reported at least one unattended birth; more than 50% of women currently breast feeding reported difficulties; 13% of women of childbearing age had received vaccinations for tetanus while in the camps; 31% met criteria for major depression.4 The current situation is undoubtedly grimmer, as renewed fighting in 2006 increased the numbers of displaced persons and disrupted channels of humanitarian aid.

Across the African continent in Liberia, one third of former combatants were females. Both female and male combatants experienced high rates of exposure to sexual violence, 42.3% of females and 32.6% of males. Mental health sequelae were high among those exposed: rates of post traumatic stress disorder (PTSD) and depression in females were 74% and 81%, respectively, and 81% and 46%, respectively, for males. The Disarmament, Demobilization, and Reintegration education program was meant to respond to the particular needs of women and girls, many of whom suffered long-term emotional and social consequences of their violent exposures. However, this program has suffered funding cuts. In addition, new violence to the region in the past 5 years has increased the need for ever-shrinking resources.5

We know from studies of disasters within our own borders that women and children are particularly vulnerable. Following the Oklahoma City bombings, women suffered higher rates of post-traumatic psychopathology than men.6 Full-term babies born in New York City in the month following September 11, 2001 had lower birth weights and lengths than matched counterparts,7 and pregnant survivors with PTSD gave birth to infants with smaller head circumferences.8

When our global neighbors enter our own borders, their problems do not disappear. A study of immigrants in Southern California primary care clinics found that 54% had been exposed to political violence.9 Past exposure to political violence was associated with depression, anxiety, panic disorder, and PTSD. In addition, exposure was associated with chronic pain, role limitations, and impaired physical functioning. It is noteworthy that only 3% of those exposed had ever been asked about this by a clinician, and none had ever discussed this part of their past with their current physician.

As global citizens, we can begin by being aware of the global burden of disease. We can ask our immigrant and refugee patients informed questions in order to account for unusual conditions and atypical presentations of common conditions. We can hold the lens of global health and human rights to the expanding knowledge and evidence base related to women’s health, and insist it be relevant and applicable to female patients throughout the world. Finally, we can join the IOM and others who endorse a distribution of resources guided by principles of social justice and humanitarian responsibility.

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Barbara Gottlieb, MD, MPH, Board Member, The Female Patient

REFERENCES

1. Committee on the US Commitment to Global Health, Institute of Medicine, National Academy of Sciences. Executive Summary. The US Commitment to Global Health: Recommendations for The New Administration. Washington, DC: The National Academies Press; 2008; 1–52.
2. Filkins D. Afghan girls, scarred by acid, defy terror, embracing school. www.nytimes.com/2009/01/14/world/asia/14 kandahar.html?_r=1&_rl. Accessed February 5, 2009.
3. Boneza RN. Sudanese internal displaced people: challenge for the future administration. www.author-me.com/nonfiction/sudaneseinternaldisplaced.htm. Accessed February 5, 2009.
4. Kim G, Torbay R, Lawry L. Basic health, women’s health, and mental health among internally displaced persons in Nyala Province, South Darfur, Sudan. Am J Public Health. 2007;97(2):353–361.
5. Johnson K, Asher J, Rosborough S, et al. Association of combatant status and sexual violence with health and mental health outcomes on postconflict Liberia. JAMA. 2008;300(6):676–679.
6. North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999; 282(8):755–762.
7. Lederman SA, Rauh V, Weiss L, et al. The effects of the World Trade Center on birth outcomes among term deliveries at three lower Manhattan hospitals. Environ Health Perspect. 2004;112(17):1772–1778.
8. Engel SM, Berkowitz GS, Wolff MS, Yehuda R. Psychological trauma associated with the World Trade Center attacks and its effect on pregnancy outcome. Paediatric Perinat Epidemiol. 2005;19(5):334–341.
9. Eisenman DP, Gellberg L, Liu H, Shapiro MF. Mental health and health-related quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. JAMA. 2003;290(5):627 –634.