Monday, July 20, 2015

Why Srebreica Matters.

 MFP physician Dr. Lewis Marshall at the refugee camp at Tuzla.

In July 1995, Medicine For Peace sent a medical team to Tuzla, Bosnia to assist displaced women and children who had survived the massacre at Srebrenica. We stayed in Bosnia for six more years, operating a school-based mental health program in Kozarac, one of the first Muslim towns subjected to the Serb campaign of ethnic cleansing.

On July 8, 2015, the U.N. Security Council debated a resolution condemning the Srebrenica massacre that occurred during the Bosnian war as a crime of genocide.

Forty thousand Bosnian Muslims sought refuge in the U.N. designated  “safe area” of Srebrenica in July 1995, under the protection of a small contingent of Dutch U.N. peacekeeping forces. The Bosnian Serb Army and Serbian paramilitaries held the often play the “atrocities occurred on all sides” card were often children and the elderly were terrorized and sexually assaulted before being forcibly expelled from the area. Over the next ten days, approximately 8,000 Muslim males, age 12-77, were systematically executed at nearby killing fields, thrown into mass graves, and covered over using bulldozers. Both the International Criminal Tribunal for the Former Yugoslavia (ICTY) and the International Court of Justice have ruled that these events constitute the crime of genocide because it was a deliberate, preconceived plan of mass executions and forced displacements with the intent of ridding Eastern Bosnia of its Muslim population. In their ruling, the International Courts relied on sworn testimonies from more than one thousand survivors, as well as forensic data from twenty years of unearthing mass graves.

Russia vetoed the Security Council resolution, with China, Venezuela, Angola and Nigeria abstaining. Russia, a fellow Christian Orthodox country, is a traditional ally of Serbia. Also, Russia and the countries abstaining have economic and military agreements with Serbia. Their statements after the vote all read from the same script: the Security Council resolution would doom the region to more tension, and that atrocities occurred on all sides of the conflict. Individuals and Governments who are apologists for the massive and disproportionate slaughter of civilians by the Bosnian Serbs and Serbian paramilitaries often play the “atrocities occurred on all sides” card.

The Serbian President, Tomaslav Nikolić, an ultranationalist in the mold of Slobodan Milošević, called the vote “a great day” for his country. His Bosnian Serb counterpart, Milorad Dodik, described Srebrenica as “the greatest sham of the twentieth century”.  Clearly, the past twenty years have not been a period of self-reflection for the majority of Bosnian Serbs or the Serbian Government. In the face of overwhelming evidence, the Serbs deny participating in what the International Courts have described as crimes of war, crimes against humanity, and genocide. The Bosnian Serbs fear that accepting a modicum of culpability might lead them to a dreaded place-- a dialogue between Muslim and Serb, and the possibility of a new vocabulary in a country where discourse is dead.

The Obama Administration appears to be on the right side of this issue. Samantha Power, the U.S. Ambassador to the U.N. supported the Srebrenica resolution. A few days later, she and former President Bill Clinton attended the twenty-year remembrance of the massacre at the Srebrenica Memorial at Portočari in Bosnia. Lest we forget the history of the Balkan Wars, the U.S. has some self-reflection to do, as well. For most of the long, four year war, the U.S. Administration maintained that it had no vested interest in the conflict, even as it watched, unmoved, while large scale atrocities against Bosnian Muslim civilians were uncovered. It was not until the eve of the 1996 U.S. Presidential elections that the Clinton Administration brokered the Dayton/Paris Peace Accords. The Accords stopped the fighting, but in separating Bosnia into Serb and Muslim/Croat entities, it legitimized the Serb ethnic cleansing campaign. The division of Bosnia has been an impediment to effective governance, and to any movement toward political reconciliation.

Finally, the Security Council’s rejection of the Srebrenica resolution reminds us of the inherent weakness of the U.N. to prevent massive human rights abuses, as witnessed in Srebrenica, Rwanda and Sri Lanka.  The U.N. has accepted responsibility for its failure to protect Muslims trapped in the Srebrenica enclave, and has implemented an action plan for early detection of human rights abuses, and effective response measures to prevent or end genocide in the committed to develop indicators of potential genocide, and effective actions to prevent or end genocide in the future. The future is now, as minorities are threatened in Myanmar, Sudan, Burundi, Central African Republic, and in Iraq. The critical question is, as it always has been, whether the U.N. member states are willing to act on the ground to protect threatened civilians.

Michael V. Viola, M.D.


Tuesday, June 16, 2015

Women's Health Month in Gros Morne

"Ankourage Sante Fanm"-Promote Women's Health- March is Women's Health month
and marks the fifth year anniversary of the MFP women's health initiative

The banner that hangs in front of the Alma Mater Hospital read , "March is Women's Health Month. Free Examinations and Treatment." Medicine and treatment have always been at no cost for our patients, but in March we waved the minimal fee that the hospital charges for clinic visits, as well. During the past months, Orna, our head nurse, spoke at all the Sunday Church services, and on the three radio stations in town.

"Protect your health. Come to the women's clinic, Do this for your children, do it for yourself."

MFP nurses walked through the market passing out flyers that explain that Haiti has the highest rate of cervical cancer in the world, and that it is a preventable disease if it is diagnosed early. Some women commented that they had friends who died of breast or cervical cancer.

On March first, women began gathering in front of the hospital at 6 a.m., waiting for the 8:30 a.m. clinic to open. Each women received a breast and gynecological examination, and was screened for cervical cancer, AIDS, syphilis, and other sexually transmitted infections. Each women who attended clinic received a bright red Medicine For Peace bracelet that said, "Promote Women's Health". Scores of women now walk through the market proudly sporting their colorful bracelets.

By the end of the month, two patients with cervical cancer were discovered and received potentially curable surgery, ten patients with pre-cancerous cervical lesions were treated with cryosurgery, eight new AIDS patients were diagnosed and placed on first line anti-retroviral drugs, and more than a hundred patients with sexually transmitted infections and other gynecological problems were diagnosed and treated. Most important, five hundred and fifty women were brought into the health care system.

There are many lessons to be learned from MFP's  women's health month. For a cancer prevention program to be successful, community education has to be ongoing, aggressive and unfaltering. In countries with entrenched poverty, even a minimal fee is an impediment to promoting comprehensive women's health. If a woman has the option of a doctors visit or a few bowls of rice, she will opt for feeding her children. Free medical care does not promote dependency, as some assert, it just prolongs women's lives.

There is a Creole saying that explains, "Analphabet pa bet". (We may be uneducated but we are not ignorant). Haitian women understand the importance of good health, and will seek out medical care if it is offered to them.

Thursday, February 12, 2015

Madame Beauchamp's Story

Nurse Orna Dieunane and Dr. Michael Viola making a house call.

Friday is outdoor market day in Gros Morne.  Orna, a nurse from our women’s health clinic, and I bargain with the women merchants for the best price for rice, beans, vegetables, cooking oil, and cans of fish. We insist on “diri jon”, the local Haitian yellow rice, which is more fragrant and tastier than the cheap rice from Arkansas that has flooded the Haitian markets. We encounter one of our nurses who has gathered a group of market women around her, encouraging them to come to our cervical cancer screening clinic. I put the food supplies on the back of our clinic motorcycle, and we head south out of Gros Morne  on National Route 5.

Four miles out of town, just beyond the bridge crossing Trois Rivière, we turn onto an unpaved mountain road, and wind our way until we came upon Madame Beauchamp’s small thatch roofed hut. We stop, and I carry the food into her one-room house. Madame was sitting in the backyard, tired and emaciated, looking older than her thirty-five years. Cancer had taken a toll. Also, it is a hard life for women in Haiti, and many women age quickly. She is talking with her mother while her three small children scurry in and out of the hut.

“How are you today, Madame?”

“Kenbe la, Dokte Mike, wi, kenbe la” I am holding on, Doctor Mike, yes, I am.

“Kenbe la” is a response that many Haitian women use. The phrase means more than just holding on.  It implies, “I am not defeated, not beaten back despite not having water or electricity, without a Haitian dollar in my pocket, and now battling this disease that is draining my strength.”

“How is the pain in your hip, Madame?”

“Not so bad, no.”

I don’t believe her. Haitians are stoic about tolerating pain, and her cervical cancer had spread to her bones. I convince her to take more analgesics.
After I return to Washington, Orna and another clinic nurse drive the motorcycle out to see Madame every few days, to make sure she has sufficient food and pain medicine. At  8 pm on a Friday night, Orna calls me by cell phone to tell me that Madame had died. Orna was by her side when she passed.

“She was too young to die, Mike,” she says in Creole.

Cancer of the cervix is a major cause of death of women in Haiti. Unfortunately, preventing cervical cancer is a complex social and medical challenge that cannot be solved by simply introducing critical technology,  like the Pap test, or the HPV vaccine. To establish a successful cancer control program, we needed to initiate a community cancer education program, establish hospital-based and mobile clinics, train nurse/educators to perform a range of gynecological procedures, and establish an
infrastructure of competent pathologists, radiologists, and surgeons capable of performing definitive cancer operations. Medical care is not free in Haiti, and at each step we subsidize a high standard of patient care.

Despite establishing an effective cancer control program, there are many women, like Madame Beauchamp, who come to us with advanced cancer. We assume the responsibility for their care , which often involves providing food,  and helping them to cope in  their day-to-day lives.

We can measure our success by the number of women we have screen for cancer, the early cancers we have eradicate, the other conditions we diagnosed and treated, and the overall improvement in women’s health in the community (see table). However, we take the greatest pride in the cadre of highly skilled and compassionate nurses we have trained, who often travel dark country roads to ensure that our patients have sustenance, are free of pain, and are living with dignity.

MFP nurses educating women on cancer prevention in the mountain village of Pendu in northern Haiti.