Dominican Medical and Dental Society - Scientific Conference

	Jaragua Hotel
	San Domingo
	Dominican Republic
	16th July 2004
	Keynote Address
	Dr. James Appleyard - President of the World Medical Association

How does the world treat our children?
Violence and Child Health

Violence is a leading public health problem. As a profession, we need to have a fundamental re-think on the role we physicians can play both to mitigate the effects of the current epidemic of violence and to develop strategies to prevent violence in the longer term.

The World Medical Association was founded in 1947 after the turbulence terror and torture of World War II to unite physicians worldwide in a shared mission founded on traditional Hippocratic principles. These have been enshrined in the Declaration of Geneva, which commits members of the profession to "consecrate their lives in the service of humanity" and to the precept that the health of each patient is their first consideration. Further work on repairing the damage of some doctors' conduct during that War was undertaken to establish the Declaration of Helsinki, which defines the ethical principles underlying clinical research. And later, after wide consultation, the Declaration of Tokyo was forged this states that doctors shall not "countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures". More recently, the Declaration of Ottawa on the Right of a Child to Health Care encouraged physicians to "eradicate all forms of child abuse''.

After the end of the "Cold War", a "peace dividend" never materialized. Expenditure of arms decreased in the early 1990s but the savings were not allocated to children's needs. A decade of ethnic conflict and civil wars ensued, characterized by deliberate violence against children on a vast scale.
Children have become targets as well as perpetrators of violence, perpetuating the cycle of violence into the next generation. During these conflicts, children have been maimed, killed, uprooted from their homes, orphaned, exploited and sexually abused. They have been abducted and recruited as soldiers. During conflicts, a country's food production is compromised, malnutrition ensures with a life-long effect, with the disintegration of the local "infrastructure".

Health services disappear and mortality rates rise. These are clearly reflected in UNICEF "league tables" of under -5 mortality rates per 1 000 live births. Those countries riven by conflict and thrown into poverty have the highest rates of childhood mortality, an enormous sacrifice that those countries cannot afford to bear.
An estimated 300,000 children are actively involved in armed conflicts. AIDS follows in the wake of such conflict, leaving large numbers of orphans and by killing teachers, health workers and public servants undermines the stability of the country. Immunization programmes disintegrate. Thus, Angola has the highest polio infection rate in all of Africa and the Democratic Republic of the Congo has had a ten-fold increase in polio since 1999. These factors leave a further burden of disability and death for the poorer countries to bear.

The epidemic of violence perpetuates poverty, giving a further twist to the vicious cycle of poverty, poor health and death to more poverty, more ill-health and more deaths. Violence becomes endemic in communities and is continued in such institutionalized cultural practices as female genital mutilation, which affects 2 million children and women worldwide. Rape and domestic violence cause 5% loss of healthy life- years. "The 20th century was one of the most violent periods in human history. An estimated 191 million people lost their lives directly or indirectly as a result of armed conflict and well over half were civilians" (Rummel R J 1994).

The risk factors are well known :

• Lack of the democratic process and denial of the rights of the individual
• Social inequity with unequal access to wealth and health
• Control of natural resources by a single group
• Rapid demographic change (Carnegie Commission).

To prevent violence, nations must

• reduce poverty and ensure developmental assistance in the form of social and health care that reaches those who need it
• reduce inequity
• reduce access to arms
• abide by international treaties.

Physicians are very much involved in the first action and by their example can encourage others to seek to achieve the other three.

The costs of violence have been calculated in Latin America. It costs Colombia and El Salvador 25% of their gross national budgets, Brazil and Venezuela about 11%, and Mexico 1.3%.
If those countries are to emerge from poverty, their internal conflicts must cease through the example of their neighbours.

We can do more to undo the harm of terror and torture which are the hallmarks of an oppressive regime by exposing the practice of torture. Physicians are in a dangerous but crucial position to identify the victims, and document their injuries so that the perpetrators can be brought to justice.
It is a gradual process. Torture is undertaken in intense secrecy though it instills fear from the knowledge that it is taking place. Once brought to the light of day with the naming and shaming of the perpetrators, the will of the people will prevail. That is why the WMA is partnering the International Council for the Rehabilitation of Torture Victims in pilot projects in five countries to promote the Istanbul Protocol which provides guidance on the identification of the injuries of torture victims so that they can be documented and the perpetrators brought to justice.

In my view, as a profession we need to do more. We must also tackle the root causes of child abuse, instill in societies non- violent means of resolving disputes, and we must start in childhood. The chastisement of children promotes a culture of violence, this is exacerbated by the more severe forms of child abuse. Idi Amin was a prime example of how devastating the long- term consequences can be.

I smacked my own children on a very few occasions. Each time, it was a failure by me as their father to manage an annoying provocative act. No one can be perfect but we can change our way of thinking and learn nurturing ways of bringing up our children. The case against chastising children is overwhelming. Under UK law, reasonable chastisement is allowed. Not to allow chastisement is more reasonable. And is more readily defined. Like the introduction of seat belts in the UK, change of behaviour comes over time even though the law is changed. The important message is that the community agrees that it does not condone violence towards children or adults. In this way, communities and the world will be a much safer place for their children and the future of the world.