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Many people with depression and other mental health problems can be treated successfully by community health workers, but so far no country has scaled up this approach. Vikram Patel talks to Fiona Fleck.

The World Health Organization is on the brink of a major transformation into an agency that is fully mandated and equipped to respond to outbreaks and humanitarian emergencies. David Nabarro talks to Fiona Fleck. Q: How did you first become interested in working in emergencies? A: When I started out as a physician during the early 1970s, I wanted to work with communities, rather than in hospitals, particularly in places where people were unable to access health services. I worked in Kurdistan in northern Iraq in 1974, in rural Nepal, eastern India and then Bangladesh. But my interest in community health was there before I studied medicine. I wanted to understand what was needed for people to be less distressed, and not to suffer when ill --wherever they lived, and whether they were poor or wealthy. When I worked in areas affected by conflict I realized that the challenges are the same as anywhere else but that it's more difficult to ensure that people can access the health care they need. Q: Can you tell us about your appointment as the UN Secretary-General's special envoy for Ebola in 2014 and how the outbreak triggered soul-searching and reconsideration of the way health emergencies are addressed? A: The outbreak was bigger than anything we'd seen before and moving so fast that organizations had to develop and revise their action plans while they were being implemented. The presidents of the most affected countries were asking the UN to play a leading role in ensuring they were properly supported. They felt abandoned. Flights to their countries had been cut. They weren't receiving the help they needed. I was working with [WHO Director-General] Margaret Chan, the Secretary-General [Ban Ki-moon] and senior advisers as they sought a massive scale-up in support of the affected countries. The Secretary-General proposed a totally new mechanism, based on what is used for UN peacekeeping operations, to give extra muscle and coordination to the international response. It became known as the UN Mission for Ebola Emergency Response or UNMEER for short. UNMEER was approved by the UN General Assembly and endorsed by the UN Security Council in the middle of September 2014: it was implemented in record time. It was developed at a time when we did not know how big the outbreak would become, with some projections that more than a million people would become infected. Q: The Report of the Ebola Interim Assessment Panel released this year found that coordination was weak between WHO and its UN and nongovernmental partners on many levels--financial, logistical etc.--during the outbreak and that WHO lacked staff capacity to respond adequately. How can the response to such emergencies be more effective in future? A: There were concerns about whether WHO sounded the alarm soon enough in the early months of 2014 and others are examining this. Since August 2014 WHO has consistently provided the technical guidance, analytical expertise and capacity to lead and this has been valued by all involved in the response. At the same time, the UN helped to bring together different UN agencies and partners, each with their sets of skills and can do this in future. As a new entity offering additional capacity for overall leadership, liaison with governments, donor engagement and logistical support, UNMEER was unprecedented and unlike any other UN operation in which I have been involved. Q: In what sense? A: If you get it right, a leadership and coordination body such as UNMEER can bring the players together like the conductor of an orchestra. Individual musicians may play beautiful melodies, but the power of harmony emerges through the skills of the conductor. We need to do more of this at the UN. There are thousands of nongovernmental groups--and some businesses as well--that yearn for effective coordination and clear direction. It is never one organization alone that responds to an emergency, partnerships are essential. …

This month the World Health Assembly discusses the post-2015 global tuberculosis strategy and accompanying set of targets. Giovanni Battista Migliori tells Fiona Fleck how his institute--one of WHO's thousands of partners across the globe --can contribute in future to its implementation, once it is approved. Q: How did you first become interested in tuberculosis? A: As a young physician, I was fascinated by the fact that although tuberculosis could be prevented, diagnosed and cured, it was still a major public health challenge. This has not changed today. At the University of Pavia, I worked with the late Gianni Acocella, one of the pioneers of treatment with fixed-dose combination anti-tuberculosis drugs, and I started my career with an Italian nongovernmental organization called CUAMM (Collegio Universitario Aspiranti Medici Missionari) in the West Nile region of Uganda, where I was assigned the coordination of tuberculosis and HIV services from 1987 to 1989. At the time, little was known about this particular co-infection and it was my job to find ways to collaborate with HIV programmes. My paper on this experience was one of the first published on the topic, years before it became a public health challenge. Today tuberculosis is a major cause of death for people infected with HIV. Q: When did you start collaborating with WHO? A: I started in Uganda while working for CUAMM. After returning to Europe in 1989, I ran an international unit at the Fondazione S Maugeri that collaborated with WHO. In the early 1990s, WHO sent me to the Russian Federation and Romania to implement the first pilots of the WHO-recommended strategy of tuberculosis control (known as "DOTS" at the time) in these two priority countries. That's when I started collaborating with Mario Raviglione, who was working at WHO with a focus on surveillance, drug resistance and eastern Europe and who subsequently became the director of the Global Tuberculosis Programme. We developed the Wolfheze documents to support WHO's policies together with the KNCV Foundation [a nongovernmental organization in the Netherlands] and the International Union against Tuberculosis and Lung Disease. These documents form the basis of Europe's tuberculosis control and elimination strategies that were launched in 1990 and that inspired the two key concepts in the draft post-2015 global tuberculosis strategy: universal coverage for tuberculosis services and the elimination of tuberculosis. Q: How did the Fondazione S Maugeri become a WHO collaborating centre? A: This happened after many years of working closely with WHO's Global Tuberculosis Programme. Apart from collaborating on the DOTS pilots and the Wolfheze documents, we also collaborated with the WHO Regional Offices for Europe and Africa, and with WHO headquarters, providing technical assistance to countries in eastern Europe and Africa. The turning point for us came in 2000, when WHO asked us to develop a special training package for tuberculosis consultants and managers. The result was the training course that we run to this day in the village of Sondalo in northern Italy. It has been rolled out in English, French, Portuguese and Russian and attended by some 2200 people who are responsible for planning, organizing, implementing and evaluating tuberculosis, tuberculosis/HIV and multidrug-resistant and extensively drug-resistant (MDR-XDR) tuberculosis control activities, that is about half of all government-run tuberculosis units globally. WHO held us up as a model of cooperation and partnership. At the time, the organization was in the process of establishing stricter rules on collaborating centres and so, in the same year the Fondazione S Maugeri became a WHO collaborating centre. Q: What are WHO and its partners doing to support the many thousands of tuberculosis practitioners working outside national programmes? A: WHO recognized that while the Sondalo course reached out to a large section of professionals working mainly on government-run tuberculosis programmes in countries, there was a need to set standards for everyone working in this field. …

Why is the same vaccine accepted in one part of the world and rejected in another? Heidi Larson tells Fiona Fleck why communicating the benefits versus the risks of vaccination is just part of the battle to gain public confidence in vaccines. Q: How did you become interested in the public response to vaccines? A: When I was leading communications for global immunization at UNICEF and chairing the advocacy taskforce for GAVI, the focus of my work was initially strategic communication, but I ended up spending more time than expected going out to countries that were facing challenges with vaccine acceptance. Most acute was the boycott of the polio vaccine in northern Nigeria 10 years ago, but there were other instances never reported by the media in which communities--and even governments--questioned certain vaccines. As an anthropologist, my job is to understand the social, cultural or political drivers of health behaviours--such as vaccine reluctance or rejection surrounding vaccination--and then to sit down with local vaccination teams and representatives from health ministries to discuss how best to communicate the need for the vaccine and, where necessary, strategies to prevent too much of a. drop in vaccine acceptance. Q: Would you agree with the assessment of the recent Report of the International Monitoring Board (IMB) of the Global Polio Eradication Initiative last year that the campaign requires more focus on communications? A: Communications can't fix a problem you don't understand. I had a sign saying this on my desk at UNICEF, because people tend to think that when there is a lack of public acceptance of a vaccine, you just need to explain the risks and the benefits to them. But sometimes the lack of confidence in vaccines is not just about communicating more effectively, but about delivery issues or different belief systems or, for example in the case of polio, needing security and diplomacy strategies, which the IMB also recognizes. O: How can medical anthropologists help? A: As anthropologists, we seek to understand what drives human behaviour and the method of study we most commonly use is "participant observation", that is embedding yourself in the community often during the course of field work. Sometimes it's about paying attention to small details that can reveal the underlying issues that are generating concerns. Q: For example? A: Before the polio vaccine boycott in northern Nigeria, we already saw pockets of resistance to the oral polio vaccine in Uttar Pradesh in northern India, although there was never a statewide political boycott. Rumours were circulating in the Indian state that vaccines sterilize recipients, but when we sat down and talked with the women from these communities, we found that their concerns were different. They didn't want their children to be vaccinated by people from Delhi or other places outside their region because if there was a problem they wouldn't know who to turn to and they didn't want their children vaccinated by men. You can have all the communications in the world about the vaccine safety, but these will never change such concerns and, ultimately, people's behaviour. When you launch a vaccination campaign, communities already have their own approach to health care and we need to understand this because, in a sense, we are trying to displace it. Q: How did you get involved in the SAGE Working Group on Vaccine Hesitancy? A: The group was formed in 2012. It's a positive step in response to an issue that has been brewing over the last decade. The biggest game changer was the polio vaccination boycott in northern Nigeria in 2003. After that, more serious consideration was given in the public health community to what had been thought of as marginal and alternative views on vaccination. Q: What is the significance of the new SAGE working group? A: There used to be a polarized view that people were either pro- or anti-vaccine. …

Space science and satellite technologies hold untapped potential for public health, according to a new expert group that will deliver its proposals to the United Nations General Assembly in New York next month. Pascal Michel talks to Fiona Fleck.

This year's World Health Day is on food safety. The mass use of antibiotics in animal husbandry is contaminating the food supply with resistant bacteria, causing difficult-to-treat infections while reducing the power of antibiotics to cure human infections. Antoine Andremont talks to Fiona Fleck. Q: Over 50% of antibiotics consumed globally are given to animals to treat or prevent infections and to boost growth. What are the consequences for human health? A: Living creatures are heavily colonized by bacteria and many of these bacteria--known as "commensal"--are beneficial for our health. When humans or animals receive antibiotics, most of the medicine is absorbed and goes to the blood, and some of it goes directly to the digestive system, where it kills most of the commensal bacteria--leaving a few bacteria that are resistant and that multiply. Some of an antibiotic that is absorbed by the blood enters the intestinal tract through biliary excretion. So, as a result of antibiotic treatment, human or animal guts contain many more resistant bacteria than those killed by antibiotics. A major consequence for human health is' that these resistant bacteria can cause infections--such as urinary tract infections--in the host, which are more difficult to treat than those caused by non-resistant bacteria. When people with weak immune systems, for instance after chemotherapy, intensive care or major surgery, have resistant bacteria in their gut, they may develop severe gut-originating sepsis, which is also difficult to treat. Another consequence for both humans and animals is that large quantities of resistant bacteria are excreted in their faeces, contaminating the environment--and possibly other humans or animals--and may enter the food-chain. Q: What are the consequences for the food-chain and the safety of our food? A: When animals that have been given antibiotics are slaughtered, it is impossible to stop all the bacteria both susceptible and resistant--in their intestine from being disseminated. So meat and other products that enter the food-chain can become contaminated. Although there are country-to-country variations, chickens you currently buy at the supermarket or butcher, are often contaminated with E. coli bacteria, which can be highly resistant to antibiotics. When you buy and take home a chicken that is contaminated with resistant bacteria, these bacteria come into contact with your hands as you prepare it, and may spread to kitchen utensils and surfaces. Resistant bacteria in chicken are killed during the cooking process. But if these bacteria contaminate salad or other foods that are eaten raw--they will not be killed. If one member of the family becomes infected with E. coil-resistant bacteria, it can easily be passed on to other family members through physical contact. So the consequences for human health are serious. Q: Are there other examples? A: There are many examples. One study [in the Journal of Emerging Infectious Diseases in August 2013] estimated that more than 1500 annual deaths in the European Union are directly related to antibiotic use in poultry. Another example is the well documented risk of transmission of methicillin-resistant Staphylococcus aureus (MRS A) from livestock to farmers, vets and others in close contact to the animals, which can result in severe infections. Q: When did we first become aware of the problem of antibiotics and resistant bacteria in the food-chain? A: In the late 1960s the Swann Report in the United Kingdom found that large quantities of resistant bacteria were being excreted by livestock into the environment following antibiotic use in husbandries. At the time no one was worried for one simple reason: new antibiotics were constantly coming on to the market to treat patients. So even if resistance was growing, it was not considered a problem for human health. Since the late 1980s, that has changed because very few new antibiotics have been discovered over the past 30 years. …

The prevention and control of noncommunicable diseases is now a top priority in many countries. Sergey Boytsov tells Fiona Fleck how the Russian Federation is collaborating with other Commonwealth of Independent States' countries. [ILLUSTRATION OMITTED] Sergey Boytsov is the Russian cardiologist coordinating the response to the biggest health threat facing his country: noncommunicable diseases (NCDs). In 2011, he was appointed director of the National Research Center for Preventive Medicine of the Russian Ministry of Health. Boytsov started his career as a naval doctor in the former Soviet Union, after graduating in 1980 from the Kirov Military Medical Academy in St Petersburg, where he went on to hold senior posts in naval and Internal medicine from 1984 to 2002. From 2002 to 2003, he joined the State Medical Center of the Ministry of Health as a senior physician and from 2003 to 2006, he was the executive director of the Pirogov Central Clinic in Moscow followed by five years as deputy director in charge of the scientific research at the Russian Cardiology Research and Production Complex. He has published many scientific papers on NCDs and is editor-in-chief of the Russian journal Preventive Medicine. Q: Health officials gathered last month to launch a project for the prevention and control of noncommunicable diseases in WHO's European Region that will lead to the opening of a WHO [geographically-dispersed office] in Moscow. What will the project do? A: This project is very important for the European Region. The Russian Federation has provided a grant of US$ 22 million to the WHO Regional Office for Europe over the next five years to build capacity in the European region to address the epidemic of noncommunicable diseases--cardiovascular disease, cancers, diabetes and chronic respiratory disease--that are the main killers in these countries. That means, among other things, providing technical support and training so that countries are able to draw up their own national plans to prevent and control these diseases. Q: How are Russian centres collaborating with other Commonwealth of Independent States' (CIS) countries, which were once part of the Soviet Union, on this challenge? A: The goal of our collaboration is to reduce smoking, to make peoples' diets healthier, to stop alcohol abuse and make people more physically active in our countries by exchanging information and sharing experiences on NCDs, building international networks and through data collection and analysis of cardiovascular and other diseases. Our centre--the National Research Centre for Preventive Medicine--is organizing collaborative international epidemiological projects with Kazakhstan and Kyrgyzstan and will soon do so with Armenia and Georgia. We are running international seminars on oncological or cardiovascular screening with Belarus and Kazakhstan. In addition, we are providing technical support to other countries. For example, we are translating WHO documents into the Russian language, such as resolutions and conference declarations, as Russian is spoken not only here in the Russian Federation but in other CIS countries. This collaboration is guided by the Global Action Plan for the prevention and control of NCDs 2013-2020 which is a great document--not just a text book--as it provides practical advice along with a timetable, indicators and goals. In addition, Moscow State Medical University is providing training on the prevention and control of these diseases and the first course was held in February last year for 25 health officials from Central Asian and east European countries. The university also provides continuing medical education for physicians from CIS countries. On the international level, our country has proposed a second global ministerial conference on healthy lifestyles and NCDs, to be held in Moscow in 2016. Q: When did noncommunicable diseases start to become a major health problem in the Russian Federation? …

"A close relative had been diagnosed with a rare disease. We searched for information on it in Arabic and found websites that were unstructured or were essentially chat forums," recalls Dr Majid Altuwaijri. "But when we searched in English we found a wealth of good quality information." As co-founder of the Saudi Association for Health Informatics, Altuwaijri was well placed to help his relative, given his expertise in information technology and fluency in English. However, globally only an estimated 600 to 700 million people have English as a second language, like Altuwaijri, in addition to some 335 million native English speakers, with varying degrees of fluency. That leaves most of the world's population--some six billion people with little or no access to a large body of public health information because it is in English. Language can be a barrier to accessing relevant and high quality health information and delivering appropriate health care--an unmet need that is amplified on a global scale. [ILLUSTRATION OMITTED] "The trend towards monolingualism is far from decreasing, with the hegemonic use of one language, English, over the other five United Nations (UN) languages," the UN Joint Inspection Unit concluded in a 2011 report on implementation of multilingualism in UN organizations. As part of the UN system, the World Health Organizations (WHO) six official languages--Arabic (242 million native speakers), Chinese (1197 million), English (335 million), French (76 million), Russian (16 million), and Spanish (399 million)--are the first languages of only 2.4 billion people, according to Ethnologue: Languages of the World, 18th edition--less than half the world's population. In addition, German (78 million native speakers) is an official language in WHO's European Region and Portuguese (203 million) in WHO's African, European and Americas Regions. For native speakers of other languages, such as Hindi (260 million native speakers) and Bengali (198 million), the unmet need for health information may be great. English has long been the lingua franca of scientists--including those working in public health--and while more WHO publications and web pages are produced in English than in any other language, WHO publications appear in more than 70 languages. All WHO's official documents, such as World Health Assembly reports and resolutions, are translated into the six official languages, but this is not the case for the rest of WHO's publishing output, including technical reports and clinical guidelines. Moreover, WHO launched its six-language multilingual website in 2005, but most of its web content is still in English. While Portuguese is the world's sixth most spoken language (after Chinese, English, Hindi, Spanish and Arabic), most Portuguese-speaking scientists seek to publish their work in English to gain wider circulation, according to a study published in a report for the European Molecular Biology Organization in 2007 by Rogerio Meneghini. In public health, the linguistic disconnect between those providing health information and those who need that information affects everyone from clinicians and patients to public health managers and policy-makers. One of the most popular health information websites, Wikipedia, collaborates with Translators Without Borders to bridge that divide. With the help of the global network of translators, Wikipedia Medicine has built a large collection of articles in more than 100 languages and has at least some medical content in more than 250 languages. "We did a lot of work for the Ebola outbreak with Translators without Borders and others because most information on Ebola was in English, which is only spoken by 15-20% of the population in West Africa," says Wikipedia editor Dr James Heilman, adding: "Now we have content on Ebola in around 115 languages. …

[ILLUSTRATION OMITTED] Sheila Tlou joined the HIV response from the outset of the epidemic in her native Botswana in 1985 and has also worked internationally to raise awareness of HIV. She is the director of the UNAIDS regional support team for eastern and southern Africa. Since 1999, she has been associate professor of nursing at the University of Botswana, where she has taught since 1980. From 1998 to 2001, she was the director of the WHO collaborating centre for nursing and midwifery development in primary health care for anglophone Africa. From 2004 to 2008, she was the health minister of Botswana. Tlou obtained her PhD In Nursing Sciences and post-graduate certificates In women's health and gender studies from the University of Illinois, Chicago, the United States of America; a bachelor of nursing degree at Dillard University, New Orleans in 1974; and two master's degrees in nursing. Tlou has received several national and international awards, including the 2002 Botswana Presidential Order of Honour. Q: What drew you to public health? A: Originally I wanted to study languages, do drama and end up in Hollywood. But when I was interviewed by the Ministry of Education for a scholarship, I was told: "In Botswana we don't eat languages, we are a developing country. We need doctors and nurses and the only scholarship available is in the health sciences". I was so disappointed. They gave me three study options: in Uganda, Zambia or Ethiopia for public health, which I chose only because of the handsome guys on the brochure. However, a scholarship to study nursing in [the United States of] America came up and I ended up in New Orleans. Q: How did you get involved in the HIV response in Botswana in the early days? A: I started teaching at the university of Botswana in 1980, and my interest was in womens health, so I became involved in gender activism and women's health issues, specifically ageing, and my subsequent doctoral dissertation was on menopause. At a regional women's health meeting in Uganda in 1984, I met Noerine Kaleeba, a Ugandan physiotherapist, who told us about the discrimination she faced in her country after her husband was diagnosed with HIV [human immunodeficiency virus]. Noerine was one of the first people to fight discrimination faced by people living with HIV. When the first case of AIDS [acquired immunodeficiency syndrome] was found in Botswana, and people started to become infected with HIV, I was determined to be part of stopping the discrimination. HIV is mainly transmitted by sex--something done by everyone--so I had a strong conviction that there should be no stigma or discrimination. I thought that within 10 years the epidemic would be over and I would go back to working on ageing and menopause. Q: Countries are pledging to end the HIV epidemic by 2030, as one of the targets of the new Sustainable Development Coals to be adopted by countries at the United Nations General Assembly this month. Is this a realistic target? A: It is a realistic target. Our confidence is based on success in achieving previous targets. For example, the target of providing 15 million people with life-saving treatment was reached in March this year, nine months ahead of the deadline. As part of our fast-track strategy, UNAIDS and our partners aim to end HIV infection as a public threat by achieving the 90-90-90 targets to keep people alive, reduce new infections. and ensure zero discrimination. The targets are that 90% of people living with HIV know their status, 90% of them are on treatment and 90% have viral suppression. Q: What are the particular risks to women's health and how did you raise greater awareness of this? A: Women are more vulnerable to HIV infection due to gender inequality in our societies. I met with several African women involved in the AIDS response at the International AIDS conference in Stockholm in 1988. We formed the Society for Women and AIDS in Africa and set up national chapters in our countries. …

At a briefing of United Nations officials on treating Ebola patients in western Africa with medicines and blood products in November last year, one question came up again and again: "Why is it taking so long?" Officials wanted to know why Ebola patients who have been evacuated to Europe or North America have had higher survival rates than those who remained in the outbreak countries, says scientist Martin Friede, who leads the technology transfer team at the World Health Organization (WHO) in Geneva. "Some of these patients had received a whole range of drugs--everything and the kitchen sink--but I explained to them that we don't know what helped them to recover. Was it the clinical care? Was it the kitchen sink?" he says. "That's why we must do clinical trials to find out which drugs are safe and effective in these patients," says Friede, a former vice-president of development at California biotech company Apovia Inc., who joined WHO in 2003. Since WHO announced news of the Ebola outbreak in Guinea last March, the United Nations health agency has received more than 200 proposals of all kinds of therapies to treat Ebola virus disease suggestions. Some suggestions--such as ingesting vulture gastric juices and plant root extracts or wearing magnets--were rejected for their lack of scientific evidence. Others, including some drugs already licensed for other diseases, as well as novel drugs specifically aimed at Ebola that are under development, have been given to Ebola patients on "compassionate grounds". So far, however, there are no definitive data available to suggest that these interventions are either effective or safe in Ebola patients. Given the urgent need for additional therapies for Ebola--currently the only recommended management is replacement of fluids and electrolytes, and good control of symptoms--WHO is taking the lead in a major international drive to test potential therapies. Since August, the UN agency has organized a series of meetings of experts to review the pipeline of potential therapies for Ebola virus disease. As of 13 January, there were 21 373 cases and 8468 deaths in Guinea, Liberia and Sierra Leone, the three countries worst affected by the epidemic. Past Ebola outbreaks were often small, confined to one community, and halted quickly by detecting and isolating cases, identifying contacts and safely burying the deceased--reasons why drug development for Ebola stalled in the past. Clinical trials of potential therapies for Ebola can only be conducted during an outbreak, but there are enormous challenges with this. "We identified only three products that work in the test tube and also give 100% protection in infected monkeys: ZMAPP (a cocktail of monoclonal antibodies), small inhibitory RNA, and anti-sense phosphorodiamidate morpholino oligomers, all targeting Ebola. [ILLUSTRATION OMITTED] "But we don't know whether these are safe or effective in Ebola-infected patients and current supplies are nonexistent or limited to quantities that are sufficient only to conduct very small clinical trials," Friede says. "So we drew up a short-list of repurposed drugs--i.e. ones developed for other conditions--including favipiravir, brincidofovir, toremefin and interferons, and we are continually reviewing this list as fresh data comes in on other drugs. "With these repurposed drugs, there is less problem with supply, but a lack of clinical evidence of their effect against Ebola," Friede says, adding that testing these drugs in animals infected with Ebola is hampered by the fact that they must be done in participating biosafety-level 4 laboratories, of which there are only a handful in the world. Each of these facilities can only handle a small number of animals at a time. Favipiravir was developed by a Japanese company, Toyama Chemical, to treat influenza and some other viral infections and is being tested in Guinea for safety and efficacy in Ebola-infected humans by a team from the Institute of Health and Medical Research (INSERM) and Paris Diderot University in France. …

The world is more aware of the problem of obstetric fistula thanks to the work of Catherine Hamlin. The Australian gynaecologist and obstetrician talks to Fiona Fleck. Q: What is an obstetric fistula? A: This is a condition which occurs when a woman is in labour for four or five days. The bony head of the baby presses on the pelvis for so long that a hole develops between the vagina and the bladder or between the vagina and -the rectum, resulting in urinary or faecal incontinence. It's possible to prevent this injury by delivering the baby by caesarean section. But in Ethiopia there are not enough doctors in the countryside able to do this operation. Women with this condition are completely ostracized from society, their husbands leave them, they have no friends, because of the smell of urine or faecal matter that leaks. Women who live with this for months, even years, often have suicidal thoughts. Repairing this childbirth injury gives them new hope and new life. Q: When you first arrived in Ethiopia, you had never seen a case of obstetric fistula in your life. How did you learn to perform surgery that had become obsolete in the developed world? A: There were things written about obstetric fistulas. We knew several doctors who had been repairing them. We had a great friend in England who used to go to India to operate and we got in touch with him. We also had manuals, drawings of the actual operation from a wonderful Cairo-based professor Pasha Naguib Marfouz, he was a great help to us. We used to talk to him, we didn't get to meet him, but we learned from his textbooks. We are gynaecologists, so we are used to operating for other things, such as stress incontinence, so we were quite familiar with the anatomy, and we soon learnt. We started with small fistulas which any gynaecologist can fix without much training, and gradually tackled more difficult ones. Q: What was it like to be a fistula surgeon in Ethiopia in the 1960s? What were the challenges in finding qualified staff and adequate medical supplies? A: We were in a hospital that was very similar to the ones in Australia. We did not find it primitive in any way. The Princess Tsehai Memorial hospital had good doctors. These doctors were trained at the American University in Beirut, and we didn't have medical training at the university in Addis Ababa until 1966. We had a good nursing school with tutors from overseas, so we were well equipped with nurses. [ILLUSTRATION OMITTED] Q: At that time, in the 1960s and 1970s, you were innovative in your field, but how did you keep up with medical knowledge before the digital age? A: We had medical journals coming, friends passing through, our doctors had trained overseas. We had Australian gynaecologists who came to work at the Princess Tsehai hospital and several English ones working in other medical fields, including an English physician and a Czech surgeon. Q: Fistula surgery is complex; spanning the boundaries of urology, plastic surgery, colorectal surgery and gynaecology. How did you succeed in providing such sophisticated tertiary care in a developing country, where primary care is often seen as the priority? A: We didn't start with the difficult cases, we started with cases that we could do. Once we were successful in curing these, we gradually took on the difficult ones. As you say, it involves urology and so many other fields in medicine apart from gynaecology, but we were able to talk to our colleagues, the urologists, and they helped us. One urologist used to come regularly from England and we would keep the urological procedures to be done by him. He also trained several of our Ethiopian doctors in this particular operation. We had a lot of visitors passing through. We had a good Ethiopian surgeon who was a great help, he was the godson of the Emperor Haile Selassie and had studied in Edinburgh. Q: One of your colleagues once said: "It's difficult to find a surgeon who is highly skilled enough to perform fistula surgery but also has the drive to work in poor countries. …

Q: Is the world ready to embrace the new women's health agenda? A: The world still focuses very much on maternal health and, more recently, family planning, which definitely reflect critical needs. The predominant view today is still of women as reproductive beings, which unfortunately leads to neglect of women's health in other stages of life. The focus on noncommunicable diseases has been growing since the 2011 United Nations General Assembly declaration, but these diseases do not receive the attention they deserve. Women's non-reproductive health is becoming important as a public health issue, mainly due to population ageing and changing lifestyles, but health systems, especially in low- and middle-income countries, are not prepared to deal with the double burden of disease among women. Q: What double burden is that? A: On the one hand, countries must address the unfinished business of sexual and reproductive health problems, malnutrition, HIV and other infectious diseases and gender-related issues, like gender-based violence and other forms of discrimination against women. On the other hand, countries must also tackle the emerging epidemic of chronic diseases. Governments are not focused explicitly on chronic diseases or allocating enough resources to deal with them. It seems that donors are not prepared to invest in the prevention, detection and treatment of chronic diseases affecting women unless more progress is made in the unfinished agenda of reproductive health. Very few researchers are working on the women's epidemic of chronic diseases in low- and middle-income countries or on the link between old and new diseases, which is important but badly neglected. Q: What is that link? A: Women face a myriad of problems in their post-reproduction years, some resulting from their reproductive health history and others that are unrelated to it. So, for instance, women may face chronic morbidities, such as obstetric fistula, pelvic pain and incontinence as a result of their pregnancies. These problems are more common in low- and middle-income countries, particularly in places where fertility is high and women do not have access to good quality health care for pregnancy and delivery. More than 80% of cervical cancer cases are due to infection with the human papillomavirus, which is acquired through sexual activity. Breast cancer incidence is growing, particularly in developing countries. This disease has a link with a woman's reproductive history, as the age at first pregnancy, number of pregnancies and breastfeeding history can increase or reduce a woman's risk of developing breast cancer. Finally, women who are obese have more complications during pregnancy and delivery. Some research suggests that the maternal mortality ratio in the United States of America (USA), which is high for a developed country, is associated with the high prevalence of obesity in the US, which also increases the risk of gestational diabetes and of chronic diabetes later in life. In developed and developing countries, the combination of obesity and high rates of Caesarean section is the perfect storm to increase maternal morbidity and mortality because surgery is riskier in women who are obese. Q: What other non-reproductive health problems do women face? A: Many chronic problems are not specific to women, although some do have links with health during pregnancy. As mentioned, obesity and diabetes affect both men and women, but the risks of developing Type II diabetes are higher among women with a history of gestational diabetes. Mental health problems, depression and anxiety-related disorders in particular, are more common among women, and some researchers believe that postpartum depression is just another manifestation of chronic depression. All over the world eating disorders represent a very important but almost invisible problem that affects mainly young women. Other problems were once more common among men but are rapidly growing among women. …

Roy Shore was the co-chair of a scientific panel that compiled the WHO Health risk assessment from the nuclear accident after the 2011 great East Japan earthquake and tsunami released in February. He talks to Fiona Fleck about the challenges of producing valid science in a highly charged environment.

Robin Coupland knows what it's like to get caught up in conflicts. In Somalia, in the early 1990s, the former war surgeon was in the operating theatre when a colleague standing next to him was shot. "There were no sandbags so we had to pile boxes of intravenous fluids against the windows" he recalls. For the past two decades Coupland, a medical adviser with the International Committee of the Red Cross (ICRC), has been working to reduce the likelihood of such incidents occurring through a mixture of advocacy and research, and. most recently by co-authoring an ICRC study titled Health Care in Danger, a first attempt to describe how and why health workers get caught in the cross fire, and what the consequences are when they do. The study was released in August last year at the start of a four-year ICRC campaign to raise awareness around the problem and make a difference to health workers on the ground. The harm done when health workers are attacked is not limited to the assault itself, but has a knock on effect that can deprive patients of treatment. This is one of the core messages of the study, which cites the example of the six ICRC health workers killed in the Chechen village of Novye Atagi (in the Russian Federation) on 17 December 1996, prompting the organization to suspend its operations in Chechnya. According to the study, this single incident deprived thousands of war-wounded of surgical care. But is health care, or are health workers, in more danger now than, say, 63 years ago when the Geneva Conventions were first drawn up? Susannah Sirkin, deputy director of Physicians for Human Rights, believes this is so. The independent research and advocacy group has been gathering information about attacks on health workers and health institutions for years. "The intensity of attacks, especially in terms of doctors being threatened, has increased," Sirkin says. But in the absence of reliable data on this phenomenon, Physicians for Human Rights, like the ICRC, can only make intelligent guesses about what is really going on. [ILLUSTRATION OMITTED] Coupland's guesses are based on two interesting observations. The first is the way in which war itself is changing. "The wounded and the hospitals are becoming integrated into the conflict'; he says, as wars are increasingly fought within rather than between countries with clearly defined fronts, where combatants are not always aware of these international conventions governing the way civilians should be treated. Because of the blurred nature of contemporary war, health facilities find themselves providing services to both sides of a conflict and exposing themselves in doing so. As Coupland points out, it is more common today for soldiers to enter a hospital to settle scores, for example, or indeed for government forces to come looking for insurgents and--as seen during last year's protests and uprisings in the Middle East--prevent doctors from treating opponents. Coupland's second observation is the ubiquity of cameras and journalists. "What happens at a hospital is a focal point for the media," he says. In his opinion this makes health care not just an integral part of a conflict but also essential to the way the conflict is viewed by the outside world. Once again, media attention tends to bring people into the hospital who do not belong there. That's why people with experience in the field go to great lengths to avert such interference and intervention when they open the hospital doors. Andrew Cunningham, Operations Adviser with nongovernmental organization (NGO) M6decins Sans Frontieres (MSF), for example, says that negotiating what he calls the "parameters of intervention" before starting operations is essential. "For Afghanistan we spent about nine months communicating and negotiating with all the relevant military and paramilitary actors to create the neutral space in which we could work before starting the programme there," he says. …

Q: Much of your work has been in the Middle East and northern Africa, what kind of mental health care is provided in these countries? A: It differs from country to country, but on the whole there is a lack of psychosocial expertise. Mental health care in many of these countries is based on traditional classical psychiatry but often they have very few psychiatrists. Psychosocial work is done mainly by small local and international nongovernmental organizations (NGOs). There is practically no civil society--although that may be changing now--so much of the mental health care response in emergencies is dependent on external initiatives and funding, which are precarious. This leads to mistakes. For example, in Gaza, people came in on emergency projects after the recent war (2008-9) working directly with local people and undermining the local services. I worked with young local counsellors and saw how their work and ambitions were damaged by these short-term emergency projects. Q: Is this typical? A: It happens after each disaster. You have a rush of interested donors, but usually these projects and interventions are short-term and, therefore, counterproductive. Whatever emergency response is needed, it should come from within the existing health system, a structure that will exist after you leave and it should not be in the form of highly sophisticated interventions by foreigners for "poor local people". Q: Are the locals also unhappy about this? A: People in need are usually happy to rcceive assistance, but in some cases it is not effective and quite inappropriate. For example, in former Yugoslavia in the 1990s, foreign NGO staffwere chased out of villages because so many people were coming in. During the recent war in Gaza, far too many international NGOs came in. They recruited staff and trained them for a few days on some aspects of trauma work, sent them around the place going from house to house looking for traumatized people. Of course, families rejected this psychological help when what they really needed was help with basic needs, such as shelter and medical care. Young counsellors working single-handedly with no team support stood helplessly offering what was not in demand. Usually trauma and stress counsellors work in a crisis team and offer services as part of a comprehensive framework. It is not surprising that the NGOs had to bring in another wave of psychologists to work with the counsellors themselves. [ILLUSTRATION OMITTED] Q: What is your approach? A: I work with the local experts and structures regardless of their knowledge and expertise. The split between emergency and development projects is a business distinction that obscures the fact that every population is in a constant process of change and development. The idea of "emergency relief" is totally distorted in the psychosocial sector because it's often only after a disaster that people get help when they needed it before. Gaza was under siege before and remains so after the war. But emergency relief was tagged to the war and has dwindled since. Six months of funding was allocated to 200 local NGOs working in the field, but none to the Ministry of Health's mental health services. Q: Does cultural background play a role? A: Every mental health intervention should be adapted to the culture, today this is a given. Even if you are prescribing medication, you must take into consideration cultural beliefs on medicines. The same with psychotherapy. As trainers, we need to adapt our approach to the people we want to help. Some schools of psychotherapy are more appropriate than others. For example, cognitive behavioural therapy is usually suitable for people from Arabic-speaking cultures. It is based on evidence and rational thinking, which are part of the Arab Islamic value-system--when your beliefs are the main basis for your behaviour and when you believe that what you do will have an impact in this life and the after life. …