[Mental health in Gaza]. / La salute mentale a Gaza.

Mental health in Gaza. The article that follows - which is the gift of one of the most competent and responsible doctors in the field of international cooperation - is not only one of the very few reports on one of the most serious and least known aspects of the repression of the population of Gaza: it would like to be a cultural and methodological reminder of how great is the invisibility of the rights denied to all the populations that permanently live in a state of war in the world. The situation described here for such a fragile part of the Palestinian population is the most explicit and tragic case in which the chronicle of wars does not accept the blackmail of telling of winners and losers, of victims and destruction, but wants to play the role of restoring visibility, dignity, windows of future to concrete people, to their unmet needs, to the demand for profound attention, which is the main way to recognise and make violated rights possible again. The mental health of the paediatric and adolescent age is a very strong indicator (also for Italy - Save the Children's annual reports describe a worrying situation) of how much society and health care leave 'orphans' precisely those who have the most difficulty in resisting-overcoming the insecurity-fragility-non-autonomy created by all types of war: their request is first of all for an adoption that needs less doctors and medicine, and much more accompaniment made up of time, acceptance, and hope for the future. The most widespread war that affects society and health today is the one which excludes the right to personalised and lasting visibility-recognition. May Gaza become a permanent school of looking and listening.

International collaborations in cancer control and the Third International Cancer Control Congress.

Over the past few decades, there has been growing support for the idea that cancer needs an interdisciplinary approach. Therefore, the international cancer community has developed several strategies as outlined in the WHO non-communicable diseases Action Plan (which includes cancer control) as the World Health Assembly and the UICC World Cancer Declaration, which both include primary prevention, early diagnosis, treatment, and palliative care. This paper highlights experiences/ideas in cancer control for international collaborations between low, middle, and high income countries, including collaborations between the European Union (EU) and African Union (AU) Member States, the Latin-American and Caribbean countries, and the Eastern Mediterranean countries. These proposals are presented within the context of the global vision on cancer control set forth by WHO in partnership with the International Union Against Cancer (UICC), in addition to issues that should be considered for collaborations at the global level: cancer survival (similar to the project CONCORD), cancer control for youth and adaptation of Clinical Practice Guidelines. Since cancer control is given lower priority on the health agenda of low and middle income countries and is less represented in global health efforts in those countries, EU and AU cancer stakeholders are working to put cancer control on the agenda of the EU-AU treaty for collaborations, and are proposing to consider palliative care, population-based cancer registration, and training and education focusing on primary prevention as core tools. A Community of Practice, such as the Third International Cancer Control Congress (ICCC-3), is an ideal place to share new proposals, learn from other experiences, and formulate new ideas. The aim of the ICCC-3 is to foster new international collaborations to promote cancer control actions in low and middle income countries. The development of supranational collaborations has been hindered by the fact that cancer control is not part of the objectives of the Millennium Development Goals (MGGs). As a consequence, less resources of development aids are allocated to control NCDs including cancer.

The quality of life of Palestinians living in chronic conflict: assessment and determinants.

This study assessed the quality of life (QoL) of Palestinians living in conditions of chronic conflict and examined its determinants. An adapted World Health Organization quality of life (WHOQoL-Bref) instrument was used in a representative sample of 1,008 adults. Factor analysis and multiple regression were conducted to determine associations between demographic and socioeconomic characteristics and scores of extracted principal determinants, and estimated overall and domain-specific QoL scores. Men, older persons and those less educated reported lower QoL than their counterparts. Negative associations were also found with higher distress and fear levels, and lower financial and freedom status. The chronic and entrenched conflict over generations resulted in lower QoL for the population of the Occupied Palestinian Territory.

Quality of life in the Palestinian context: an inquiry in war-like conditions.

This study aims to elucidate the concept of quality of life (QOL) in a unique environment characterized by protracted and ongoing conflict, beginning with the utilization of the WHOQOL-Bref as a starting point for discussion. It works to determine important health-related quality of life domains and items within each domain, and evaluate issues pertinent to the Palestinian population's understanding of life quality in the Occupied Palestinian Territory. Focus group discussions (FGD) were conducted with individuals living in the Gaza Strip and Ramallah District of the West Bank. Participants were asked if they understood the term QOL; and about the determinants of their own QOL, using open-ended questions. Participants were then presented with the WHOQOL-Bref questions and requested to assess their relevance and importance in determining their own QOL, and encouraged to suggest additional ones. A total of 150 men and women of various ages and socioeconomic classes participated in 13 FGD. A major finding is the all-encompassing impact of the political context on Palestinians' QOL assessment. The study demonstrates that political freedom, self-determination, participation in democratic processes and feeling involved in political decision-making are considered important contributors to people's QOL. The study raises the option of adding a new domain to the WHOQOL-Bref, allowing the study of its psychometric properties and its relationship to the rest of the instrument. This contribution should be particularly relevant to societies and cultures in conflict-affected zones and locales where violence and insecurity constitute an important part of life. The documentation of QOL, beyond fatal and non-fatal health outcomes, must remain an important objective of all evaluations in order to guide policy and resource allocation decisions directed towards improving peoples' lives in general and their health in particular.

Chagas Disease in a Non-endemic Country: A Multidisciplinary Research, Bologna, Italy.

Global processes have brought about a substantial change in the epidemiological landscape of Chagas disease, spreading it to non-endemic areas. Italy is the second country in Europe in terms of Latin American migrants and expected infection rate. Given that scenario, the Bologna University Teaching Hospital undertaken a study aimed at providing preliminary data on the prevalence and investigating the knowledge and the subjective perceptions of Chagas disease, migration pathways and other relevant ill-health experiences. A cross-sectional study was undertaken in association with an ethnographic research. Between November 2010 and May 2013 Chagas disease testing was offered to people who attended the hospital and data were collected to investigate the broader socio-demographic and cultural factors. 151 individuals were screened for anti T. cruzi antibodies; 12 of them, 10 Bolivians and 2 Argentinians, were seroreactive, resulting in an overall prevalence of 7.94 %. Both the quantitative and the qualitative analysis revealed a degree of heterogeneity in terms of knowledge and perceptions of the disease as well as of migration pathways. The results are comparable with those reported by previous studies with similar characteristics and highlight the relevance of such public health issue in a non-endemic context. Moreover, the interdisciplinary approach has greatly helped to unveil the complex social and cultural implications of Chagas disease, to explain the subjective ill-health experiences, and to understand the ways in which the broader socio-economic and cultural context affects an intervention and its potential for success or failure.

Dehydroepiandrosterone-sulfate serum levels and common age-related diseases: results from a cross-sectional Italian study of a general elderly population.

The association of low serum dehydroepiandrosterone sulfate (DHEAS) levels with age, lifestyle, general health status indicators, and specific diseases was investigated in 436 men and 544 women of 65-97 yr old. In both sexes low serum DHEAS levels were associated with age, alcohol intake, number of current medications, and decreased thyroid function. Low DHEAS was also associated with low serum albumin in men and low systolic blood pressure in women. Compared to healthy men (n=106) age-adjusted serum DHEAS levels were significantly lower in men with atrial fibrillation, chronic obstructive lung disease, dementia, parkinsonism, cancer, diabetes, hypothyroidism, and in institutionalized men. Compared to healthy women (n=100) age-adjusted serum DHEAS levels were significantly lower in women with occlusive arterial disease, chronic obstructive lung disease, and osteoporosis. After controlling for differences in lifestyle and general health status parameters, low DHEAS levels remained statistically associated only with atrial fibrillation in men and osteoporosis in women, and it cannot be excluded that these association were spurious, due to multiple comparisons. These data suggest that in elderly people low serum DHEAS levels are more a non-specific indicator of aging and health status than a risk indicator of specific diseases.

Crise econômica, desigualdades, direitos humanos e ética dos sistemas de saúde no contexto globalizado / Economic crisis, inequality, human rights and healthcare ethics in the global context

As escolhas relacionadas a alocação de recursos na Saúde Pública são constantemente pontos críticos, tanto em períodos de expansão econômica, quanto em períodos de crise. Em ambos os casos, as escolhas por racionamentos escondem numerosos perigos para a saúde da população, especialmente, quando são realizadas por meio de uma abordagem técnico-racional e sem reflexões éticas específicas. O racionamento feito a partir de decisões políticas raramente levam em consideração as reflexões estruturais do tipo ético sanitário, que deveriam ser utilizadas na organização, gestão e avaliação das políticas e serviços de Saúde. Este artigo visa fomentar o debate entre os profissionais de saúde, aos gestores e aos estudantes, demonstrando os riscos implicados na alocação dos recursos em saúde, por meio de um processo técnico-racional. Foram analisados referenciais teóricos e estudos de casos internacionais, relativos ao período pós Segunda Guerra Mundial até os dias atuais. A análise se constitui a partir da experiência e formação dos autores, bem como na capacitação dos profissionais de saúde tanto no contexto europeu, quanto no contexto brasileiro. O artigo reflete sobre a necessidade e a importância do "fazer ética", do ser sensível a diversidade moral em um mundo globalizado, procurando trazer potência na compreensão e mediação dos conflitos relacionados ao financiamento em saúde.

Le scelte allocative rappresentano una criticità costante in salute pubblica sia in periodi di crescita economica sia in periodi di crisi. In tutti i casi le scelte di «razionamento¼ nascondono numerose insidie per la salute della popolazione, specialmente quando sono realizzate attraverso un approccio tecnico razionale e senza il supporto di specifiche riflessioni di natura etica. Infatti anche se il «razionamento¼ viene frequentemente presentato dai decisori politici e dai gestori come uno strumento per la promozione della salute quale diritto umano fondamentale, raramente riflessioni strutturate di tipo etico sanitario sono utilizzate nell'organizzazione, gestione e valutazione delle politiche sanitarie e dei servizi di salute. L'articolo tenta di fornire ai professionisti sanitari, ai gestori e agli studenti stimoli al ragionamento rispetto ai rischi insiti nell'allocazione delle risorse in salute eseguite solo attraverso processi tecnico-razionali. Sono stati quindi raccolti e riassunti i principali contributi teorici ed alcuni case studies internazionali relativi al periodo che va dal secondo dopoguerra ad oggi utilizzati dagli autori nella formazione rivolta ai professionisti sanitari sia nel contesto europeo sia nel contesto brasiliano. L'articolo dopo una riflessione estesa ed articolata conclude riaffermando la necessità e l'importanza del "fare etica" e dell'essere sensibili alle diversità morali, nel contesto pluralista del mondo globalizzato, sopratutto come strumento per la comprensione e la gestione dei conflitti che le scelte allocative in salute producono nel campo sociale.

Allocation decisions are a critical constant in public health both in periods of economic growth and in times of crisis. In all cases "rationing" choices hide many dangers to the health of the population, especially when they are made through a rational, technical approach and without the support of unambiguous ethical considerations. In fact, even if "rationing" is frequently presented by policy makers and managers as a tool for the promotion of health as a fundamental human right, well-thoughtout, ethical reflections on health are rarely used in the organization, management and evaluation of health policies and health services. The article aims at encouraging health professionals, managers and students to reflect on the risks inherent in resource allocation in health driven only by technicalrational processes. A number of significant, theoretical contributions are presented, together with international case studies from World War II to the present, utilised by the authors to train health professionals both in Europe and in the Brazilian context. After an extensive and articulated discussion, the article concludes reaffirming the need and importance of "doing ethics" and being sensitive to moral diversity, in the pluralist context of the globalized world, as a tool for understanding and managing conflicts generated in society by healthrelated allocation decisions.

The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe.

This paper reports on comparative analysis of health planning and its relationship with health care reform in three countries, Eritrea, Mozambique and Zimbabwe. The research examined strategic planning in each country focusing in particular on its role in developing health sector reforms. The paper analyses the processes for strategic planning, the values that underpin the planning systems, and issues related to resources for planning processes. The resultant content of strategic plans is assessed and not seen to have driven the development of reforms; whilst each country had adopted strategic planning systems, in all three countries a more complex interplay of forces, including influences outside both the health sector and the country, had been critical forces behind the sectoral changes experienced over the previous decade. The key roles of different actors in developing the plans and reforms are also assessed. The paper concludes that a number of different conceptions of strategic planning exist and will depend on the particular context within which the health system is placed. Whilst similarities were discovered between strategic planning systems in the three countries, there are also key differences in terms of formality, timeframes, structures and degrees of inclusiveness. No clear leadership role for strategic planning in terms of health sector reforms was discovered. Planning appears in the three countries to be more operational than strategic.

From Alma-Ata to the Global Fund: the history of international health policy / De Alma-Ata ao Fundo Global: a história da política internacional de saúde

Verticalization of health care delivery, in one form or another, is the common theme pervading the history of international health policy over the last sixty years. It is often accompanied by radical policies of privatization of health services, everywhere resulting in people being forced to pay for all services. The failure of the vertical approach, of which the global public-private partnership initiatives are a modernized version, has been well recognized and its reasons are clear: actions on the distal determinants of disease (income, education, housing, the environment and infrastructure, etc) are overlooked; distribution of services dedicated to specific diseases and interventions (such as AIDS, malaria, tuberculosis, etc.) are artificially and temporarily reinforced, creating absurd and harmful forms of competition between services and making even more precarious and inefficient the work of already fragile basic health systems. This article describes the role played in this disturbing historical development by the prevailing economic ideology and its operational arm, the World Bank, with the view to reclaim international policy making processes and actors that really respond to people's health needs.

A verticalização da assistência à saúde, de uma forma ou de outra, é o tema comum que permeia a história política internacional de saúde ao longo desses últimos sessenta nos, muitas vezes acompanhada com políticas radicais de privatização dos serviços de saúde, resultando, em todos os lugares, na obrigatoriedade de pagamento pelo povo, de todos os serviços. A falência da abordagem vertical, cujas iniciativas de parcerias globais público-privadas constituem sua versão moderna, tem sido reconhecida, tendo sido claras as suas razões: negligenciamento das ações sobre os determinantes distais das doenças (renda, educação, moradia, o ambiente e a infra-estrutura, etc.); a distribuição de serviços dirigidos para doenças específicas e intervenções (tal como AIDS, malária, tuberculose, etc.) é artificial e temporariamente reforçada gerando maneiras perigosas e absurdas de competição entre os serviços e tornando o trabalho já frágil dos sistemas de saúde ainda mais precário e ineficiente. Esse artigo descreve o papel exercido neste desenvolvimento histórico perturbador ocasionando pela ideologia econômica predominante e seu braço operacional, o Banco Mundial, com o objetivo de reclamar que o processo de decisão política internacional e seus atores realmente respondam pelas necessidades de saúde do povo.